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Thyroid  Cartilage 


Crico-Thy  oid  Membran.3  -  V- V\ 
and  Artery.  L_  \\  ; 

Cricoid  Cartilaga— ^^h 


Superior  Thyroid  vein 


Infer,  Thyroid  V- 
Arteria  imiorainat; 


A   TREATISE 


■ON  — 


DIPHTHERIA 

Historically  and  Practically  Considered; 


—   INCLUDING  — 


Croup.  Tracheotomy  and  Intubation. 


By    a.    SANNE, 

Docteur   en   Medecine,    Ancien   des    Hopiinux   de   Paris,   Memhre    de    tu   Societe 

Anatomigue,  Des  Societes  de  Medecine  de  Nancy,  de  Genhve,  etc. 

Chevalier  de  la  Legion  d' Honneur. 


Translated,  annotated 

AND   THE    SURGICAL   ANATOMY   ADDED;    ILLUSTRATED    WITH 

A   FULL-PAGE    COLORED    LITHOGRAPH.   AND 

MANY   WOOD    ENGRAVINGS. 


By  henry  z.  gill,  A.m.,  m. d.,  l l.  d., 

Late  Professor  of  Opera.fire  and  Clinical  Snrgcry  in  the  Medical  Department  of 

the    Uniuersity  of  Wooster.  at    Cleveland.    0. ;    Manber   of 

the  American  Medical  Association,  Etc. 


St.   Louis.  Mo.  : 

J.  II.   CHAMliERS   &   CO., 

1887 


COPYRIGHTED    1 887. 

By  J.  H.  CHAMBERS. 

ALL   RIGHTS     RESERVED. 


mi 


TO 

PROFESSOR   EDMUND   ANDREWS,  M.D.,  LL.D., 

AS   A  TRIBUTE  OF   RESPECT 

FOR   HIS    MORAL   WORTH,    LITERARY   ATTAINMENTS,*   AND    DISTINGUISHED 
RANK   IN   THE   MEDICAL   PROFESSION, 

AND    IN    ACKNOWLEDGMENT   OF  PERSONAL  FAVORS   AND   ENCOURAGEMENT  IN  THE 
PROSECUTION   OF  THE  WORK,   IS  THIS 

TREATISE, 

IN   ENGLISH    DRESS,    SINCERELY   DEDICATED, 

BT  HIS  FRIEND, 

THE  TRANSLATOR. 


INTRODUCTION. 


Since  the  period  at  which  the  immortal  work  of  Bretonneau 
on  diphtheria  appeared  numerous  investigations  have  been 
made,  and  publications  of  great  interest  have  issued  from  the 
press.  The  most  celebrated,  those  'which  came  from  Trous- 
seau, have  supplemented  the  description  of  the  disease  by  ac- 
cessories which  had  escaped  his  predecessor.  The  labor  of 
these  two  illustrious  physicians  has  remained  standing  in  its 
truly  original  portion — in  that  which  concerns  the  doctrine  of 
specificity.  Their  theories  have  undergone  the  test  of  time  ; 
they  have  resisted  powerful  attacks,  but  now  see  returning  to 
them  a  medical  generation,  shaken  for  a  moment  by  specula- 
tions prematurely  erected  upon  controvertible  data. 

But  the  disease  has  continued  its  career,  and  has  extended 
almost  to  the  entire  world ;  its  study  has  been  pursued  with 
perseverance  ;  new  views  have  been  enunciated,  and  certain 
important  phenomena  have  been  carefully  examined  if  not 
fully  explained. 

These  elements,  scattered  through  science,  must  be  col- 
lected, classified,  the  approved  acquisitions  noted,  the  state  of 
our  knowledge  upon  points  still  in  dispute  set  forth  and,  at  the 
same  time,  must  indicate  the  results  of  personal  research,  and, 
finally,  present  diphtheria  in  its  complete  entirety. 

I  have  undertaken"this  task ;  I  have  felt  myself  irresistibly 
attracted  to  it.  For  a  long  time  my  thoughts  were  directed  in 
this  channel ;  being  a  student  of  Barthez  and  of  Trousseau, 
two  teachers  who  have  contributed  largely  to  the  progress  of 
this  branch  of  pathology,  I  have  been  able  to  study  diphtheria 
very  closely.  As  early  as  1869,  I  undertook  to  investigate  a 
part  of  the  subject,  quite  limited  in  appearance,  that  of  the 
sequences  of  tracheotomy ;  and  we  have  seen  by  the  develop- 
ments into  which  I  have  entered,  what  a  conspicuous  place  it 
should  occupy.  The  materials,  so  extensive,  which  I  had 
barely  touched,  so  to  speak,  at  that  time,  offered  me  in  pro- 

(5) 


VI  INTRODUCTION. 

fusion  the  desirable  resources.  They  have  since  been  in- 
creased by  an  immense  number  of  observations  made  by  my- 
self at  the  Sainte  Eugenie,  or  coming  from  my  private  prac- 
tice in  the  city;  I  have  been  able  to  add,  also,  notes  taken  of 
all  the  cases  of  diphtheria  entering  the  service  of  Barthez, 
from  1869  to  1875,  notes  which  this  eminent  teacher  has 
placed  at  my  disposal  as  he  had  already  done  those  of  the  pe- 
riod from  1854  to  1869.  The  work  which  follows  is,  therefore, 
the  substance  of  about  fifteen  hundred  observations.  Numer- 
ous facts,  extracted  from  several  theses  and  memoirs  on  diph- 
theria, have  also  been  placed  under  contribution.  I  have  en- 
deavored to  make  known  the  state  of  the  question  in  France 
and  abroad ;  one  will  find  a  brief  statement  of  the  principal 
epidemics  which  have  occurred  in  the  old  and  in  the  new 
world,  and  the  statistics  will  set  forth  the  results  of  tracheot- 
omy in  many  of  these  countries.  To  have  produced  accurate 
accounts  of  the  invading  march  of  this  plague  in  France,  and 
of  the  track  over  which  it  has  traversed  annually,  would  have 
been  very  instructive.  The  reports  of  the  committee  on  pre- 
vailing diseases,  edited  by  E.  Besnier,  and  the  mortality  tables 
published  by  the  prefecture  of  the  department  of  the  Seine, 
have  furnished  me  positive  data  of  the  course  of  the  disease 
in  Paris  for  some  years  past.  The  provinces  have  furnished 
me  information  much  less  definite  ;  the  unfortunate  interrup- 
tion which  one  observes  in  the  reports  of  the  epidemics  pre- 
vents establishing  complete  statistics.  I,  therefore,  join  with 
authorized  physicians  who  have  demanded  the  reorganization 
of  this  service. 

I  may  not  close  without  thanking  MM.  Barbosa,  of  Lisbon ; 
d'Espine,  of  Geneva ;  Henriette  and  Warlomont,  of  Brussels, 
and  Letourneau,  of  Florence,  for  the  valuable  documents  which 
they  have  so  kindly  transmitted  to  me  with  equal  promptness 
and  liberality. 

A.    SANNE. 
Paris,  July,  1876. 


TRANSLATOR'S    PREFACE. 


About  eighteen  years  ago  the  question  of  the  nature  of  diph- 
theria and  of  membranous  croup — its  oneness  or  duaUty — at- 
tracted my  special  attention  and  study.  Having  become  ac- 
quainted with  the  German  view  from  the  personal  instruction 
of  Virchow,  and  then  examining  the  subject  as  held  by  the 
French,  and  those  two  views  so  diametrically  opposed  as  divid- 
ing the  suffrages  of  the  English  and  American  authors  and 
teachers,  the  subject  grew  upon  my  thought  both  in  interest 
and  extent.  Was  there  no  way  of  solving  the  problem — no 
way  of  reconciling  the  differences  ?  To  adopt  the  views  of 
the  one  class  of  observers  was  to  reject  the  clinical  facts,  and 
teachings  deduced  therefrom,  of  the  other  equally  competent 
and  of  equal  experience. 

Having  observed  in  discussions  before  medical  societies  the 
vagueness  in  many  practising  physicians  as  to  the  reasons  for 
the  use  of  certain  remedies,  as  well  as  the  positive  dicta  of 
others  as  to  the  difference  between  the  membranous  manifes- 
tations in  the  pharynx  on  the  one  hand  and  in  the  larynx  oit 
the  other,  and  especially  in  the  only  treatment  in  many  casei 
(tracheotomy)  which  could  possibly  afford  any  chance  of  reliel 
or  of  hfe,  I  read  everything  regarded  of  high  authority  that  1 
could  command,  either  in  German,  French  or  English,  which 
had  for  its  object  the  investigation  of  the  nature  of  the  mem- 
branous diseases  of  the  throat  and  air-passages.  Very  soon 
after  its  appearance  in  the  original  I  imported  Sanne's  work. 
Its  fullness,  taking  every  feature  of  the  subject  under  consider- 
ation, tracing  its  history  down  through  the  centuries,  the 
clinical  observations,  the  pathological  manifestations,  micro- 
scopical and  clinical  examination,  and  its  inoculation — I  con- 
fess the  whole  question  grew  in  interest  until  it  became  almost 
a  charm.     At  the  same   time,  or  a  little   before,  operating   on 

(7) 


VIU  PREFACE. 

some  cases  for  laryngeal  obstruction  (croup)  with  very  encour- 
aging success,  I  set  about  investigating  the  status  of  the  question, 
including  the  operation  of  tracheotomy,  for  the  lar^mgeal  form 
of  the  disease,  in  the  entire  state  of  Illinois,  aiming  to  obtain 
the  doctrines  held,  and  the  treatment,  medical  and  surgical, 
adopted  by  the  profession  there,  and  to  collect  every  case  of 
tracheotomy  that  had  ever  been  performed  in  the  state  for  this 
disease  (croup),  with  details  of  the  operation.  After  most  dili- 
gent investigation  and  extensive  correspondence,  continued 
until  1 88 1,  the  number  of  operations  reported  reached  151,  of 
which  38  recovered — a  number  sufficiently  large  to  encourage, 
certainly,  the  repetition  of  the  practice  in  all  suitable  cases.  In 
the  above  correspondence  I  was  particularly  impressed  with 
the  confused,  limited  and  erroneous  views  held  by  many  on 
the  natui-e  of,  as  well  as  the  practise  in,  this  very  important 
disease. 

When  we  recall  the  fact  that  every  year  thousands  die  in  the 
United  States  of  diphtheria  either  with  or  without  the  laryn- 
geal complication  (in  1880,  according  to  the  United  States 
census,  38,398,  or  52.32  to  the  1,000  of  all  deaths  with  cause  re- 
corded), it  becomes  every  general  practitioner  to  fully  inform 
himself  of  the  established  facts  of  the  disease,  as  well  as  of  the 
questions  still  under  investigation.  A  passage  here  from  Prof. 
Jacobi's  article  in  "  Pepper's  System  of  Medicine,"  will  be  in 
point : 

"  It  is  a  matter  of  regret  that  the  limited  space  allotted  to 
this  subject  should  exclude  much  historical  detail  of  the  etiol- 
ogy, pathology  and  therapeutics  of  diphtheria.  If  history  of 
any  disease  is  interesting,  and  the  neglect  of  its  study  has  ever 
punished  zVi'^//' [italics  ours]  it  is  diphtheria.  Particularly  would 
the  treatment  have  been  more  successful  if  the  knowledge  of 
former  times  had  been  available  and  more  heeded." 

In  this  volume,  that  regret  may  not  arise,  if  the  reader  will 
have  the  industry  to  read,  and  exercise  the  intelligence  to  ana- 
lyze the  material  herein  presented,  both  theory  and  practice, 
may  we  not  confidently  hope,  will  be  greatly  advanced,  and 
in  the  result  many  lives  be  saved.     I  have  used  the  metric  sys- 


PREFACE.  IX 

tern  of  weights  and  measures,  not,  however,  omitting  the  one 
in  more  common  use,  though  with  the  hope  of  aiding  in  the 
early  general  adoption  of  the  former.  The  Arabic  has,  in  both 
cases,  been  used  rather  than  the  Roman  numerals.  For  this 
I  make  no  apology. 

I  had  prepared  a  bibliography,  chronologically  arranged,  of 
over  thirty  fools-cap  pages,  but  upon  farther  considering  the 
matter,  it  occurred  to  me  that,  for  the  general  practitioner,  it 
would  be  of  little  interest ;  and  because  any  one  making  an  ex- 
tensive investigation  of  any  of  the  questions  connected  with 
this  subject  would  have  access  to  "  The  Index-Catalogue  of  the 
Library  of  the  Surgeon-General's  Office,"  to  be  found  in  nearly 
all  public  libraries  ;  and  for  the  farther  reason  that  it  seemed 
necessary  to  bring  the  limits  of  the  work  within  some  reasona- 
ble bounds. 

It  is  fitting  and  a  pleasure  to  acknowledge  the  promptness 
and  courtesy  of  my  friends  who  have  aided  in  various  ways  in 
carrying  forward  the  work  which,  under  the  circumstances  of 
delivering  two  annual  courses  of  lectures  on  clinical  and  oper- 
ative surgery  at  the  college,  and  acting  as  registrar  and  treas- 
urer, has  been  no  easy  task.  Nothing  short  of  the  conviction 
of  the  intrinsic  value  of  the  work  would  have  held  me  to  its 
prosecution. 

The  addition  of  the  surgical  anatomy  of  tracheotomy  was 
an  original  thought  with  the  translator ;  and  Prof.  E.  Andrews 
consented  and  prepared  some  matter  for  it.  But  an  unforeseen 
and  unavoidable  delay  occurred  in  the  carrying  out  of  the 
original  plan;  and  the  Professor,  in  the  meantime,  assumed  other 
duties  which  made  it,  at  a  later  date,  impossible  to  complete 
the  former  purpose.  Other  arrangements  had  to  be  made. 
My  friend,  Dr.  Lewis  S.  Pilcher,  of  Brooklyn,  N.  Y.,  most  gen- 
erously placed  at  my  disposal  his  article  and  the  accompanying 
illustrations  on  the  anatomy  of  the  "  Pretracheal  Region."  I 
have  used  much  of  it  literally  and  liberally,  and  for  it  he  has 
my  warmest  thanks. 

Dr.  Harry  K.  Bell,  of  the  "  Sanitarian,"  very  kindly  prepared 
for  me  a  "  Report  of  the  Mortality  from  Diphtheria  and  Croup 


X  PREFACE. 

in  the  United  States,  during  the  year  1883,"  including  nearly 
all  the  larger  towns  and  cities,  for  the  several  weeks  reported. 
But  as,  in  many  cases,  several  weeks  were  omitted,  I  could  not 
use  the  report.  I  have,  therefore,  selected  a  number  of  the 
larger  cities  of  the  Union,  and  have  given  the  mortality  from 
diphtheria  and  croup  for  the  years  1883  and  1884.  This  one 
table,  if  no  other  reason  were  given,  would  be  justification  for 
the  publishing  of  the  following  pages. 

The  translation  has  been  made  in  the  intervals  of  other 
work.  It  was  very  difficult  to  obtain  assistance.  Teachers  of 
French  do  not  always  understand  idiomatic  English,  and  but 
few  of  those  who  do  are  familiar  with  medical  language  ;  hence, 
it  became  necessary  for  me  to  reread  and  correct  nearly  all  the 
work.  Miss  Annie  B.  Irish,  Professor  of  the  German  Lang- 
uage and  Literature  in  the  University  of  Wooster,  revised  a 
portion  of  my  first  chapters,  but  distance  and  her  engagements 
made  it  impracticable  to  further  continue  that  assistance.  Dr. 
L.  B.  Tuckerman  kindly  aided  me  in  the  latter  part  of  the 
translation,  other  duties  requiring  so  much  of  my  time.  Finally, 
the  whole  was  reread  by  me  with  M.  Lejeane,  a  Frenchman  by 
birth  and  education.  Did  time  permit,  it  would  be  a  pleasure 
to  read  even  again  the  entire  volume,  and  in  some  cases  to 
transpose,  and  to  abbreviate  in  many  cases  ;  but  believing  that 
the  facts  and  sentiments  are  set  forth  in  sufficiently  clear  terms 
to  be  understood  it  must  now  go  to  the  reader,  fully  aware  as 
we  are  that  some  mistakes  may  still  be  found. 

The  author  kindly  gave  me  full  permission  to  make  the  trans- 
lation, and  has,  since  the  first  permit,  also  sent  me  his  article 
on  Diphtheria  to  be  found  in  the  Cyclopoedia  Medical  of  a  still 
later  date  of  which  I  have  availed  myself 

I  have  added  very  recently  some  pages  on  hitubation,  a  pro- 
cedure now  re-attracting  the  attention  of  the  profession.  In 
all  over  50  pages  have  been  added  to  the  original  work. 

Cleveland,  O.,  Oct.  i,  1886. 


TABLE     OF     CONTENTS. 


Frontispiece.    Pseudo-Membranous  Cast. 

Preface. 

Surgical  Anatomy,      -       -       -       -       -       -       -       --       -        i  —  32 

Introduction. 

Definition.     History. 

Pathological  Anatom/,     --  -------52 

FIRST    CLASS. 

Primary  Lesions  of  the  False  Membrane,      ------        53 

Supports  of  the  False  Membrane,  ---.----76 

SECOND    CLASS. 

Lesions  of  Apparatus,        _...---.--        81 
Symptoms,    -------------129 

General  Description  of  Diphtheria,  -        -        -        -        -        -        i;,i  —  188 

Localizations  of  Diphtheria,       -------        1S9  —  264 

Course.    Duration.     Termination,         _-.-.--        265 

Recurrence.     Diagnosis,  -._ 267 

Etiology,  ----- 303 

Epidemics,         -----------        304  —  358 

Nature  of  Diphtheria        ---------    359  —  374 

Prognosis,    ------------    375  —  386 

Treatment.         ------------        387 

General  Treatment,         ----------        457 

Surgical  Treatment,     ---------        458  —  555 

Sequences  of  Tracheotomy,  -------        536  —  635 

Complications  574 

Intubation  of  the  Glottic,  --------        635  —  641 

Prophylaxis,     -----------       652  —  656 


LIST    OF    ILLUSTRATIONS. 


Fig. 

2. 

Fig. 

3- 

Fig. 

4. 

Fig. 

5- 

Fig. 

6. 

Fig. 

7- 

Fig. 

8. 

Frontispiece, 

Membranous  Cast  from  the  Air-Passages. 

Fig.  la.  The  vessels  of  the  pretracheal  space,  natural    size  ;    from  a  child  of 

three  years,  4 

Fig.  i^.  The  deep  layer  of  the  superficial  fascia  with  the  anterior  jugular  ve- 
nous plexus  —  typical  arrangement,  5 
Single  median  anterior  vein,  6 
Anterior  jugular  venous  plexus,  6 
Anterior  jugular  venous  plexus,  6 
The  anterior  cervical  muscles,  8 
The  pretracheal  space  with   typical  arrangement   of  vessels  and  of 

thyroid  gland,  from  nalure,  8 

Larynx  and  trachea  of  child  of  six  years,   nataril   size,  isthmus  ab- 
sent.    Pyramid  of  Lalouette  on  left  side.  II 
Transvers'j  anastomosing  superior  thyroid  artery  of  large  size;    a'^- 

normal  course  of  the  crico- thyroid  branch,  12 

Fig.  9.     Irregular  course  of  the  superior  thyroid  artery  wijh  anomalous   sub- 
hyoid and  crico-thyroid  branches,  13 
Figs.  10  —  11.  Inferior  thyroid  venous  plexus,                                                                14 
Figs.  12  —  13.  Inferior  thyroid  venous  plexus,                                                                15 
Fig.  14.  Inferior  thyroid  venous  plexus,                                                                             16 
Fig.  15.  Inferior  thyroid  veuous  plexus,                                                                            17 
Fig.  16.  The  pretracheal  space.                                                                                      20 
Fig.  17.  Innominate  ariery  crossing  trachea  transversely  at  a  high  point,                   21 
EiG.  18.  The  four  great  vessels  arising  separately  from  the  arch  of  the  aorta,             21 
Fig.  19.  The  four  great  vessels  arising  separately  from  the  arch  of  the  aorta; 
the  right  subclavian  and  left  carotid  crossing   in   front  of  the 
of  the  trachea  above  the  sternum,                                                               22 
Fig.  20.  The  four  great  vessels  and  the  left  vertebral  arising  separately  from 
the  arch  of  the  aorta;  right  subclavian    from   left   side  of  arch, 
passing  behind  others  in  front  of  trachea  to  its  proper  side,                   22 
Fig.  21.  Carotids  arising  by  a  common  median    trunk  between    the  origins 

of  the  subclavians,  23 

Fig.  22.  Carotids  arising  by  a  common  trunk  on  right  side,  right  subclavian 
from  left  side  of  arch,  passing  behind  others  in  front  of  trachea 
to  its  prooer  side,  23 

Fig.  23.  Right  primitive  carotid  and  subclavian  arising  separately  from  arch 

of  aorta  ;  innominate  on  left  side,  23 

(12) 


LIST    OF    ILLUSTRATIONS    CONTINUED.  Xlll 

Fig.  24.  Right  subclavian  arising  from  the  arch  of  the  aorta ,  both  primitive 
carotids  and  the  left  subclavian  by  a  common  trunk  on  the  left 

side,  23 
Figs.  25  —  28.  Anomalies  in  the  arteries  arising  from  the  arch  of  the  aorta, 

Figs.  29  —  34.  C  aliber  of  the  larynx  at  different  points,  and  at  different  ages,  32 

Fig.  35.  Dr.  Packard's  substitute  for  tracheotomy  tube,  513 

Fig.  36.  Dr.  L  N.  Himes'  case  of  polypoid  groA^th  in  the  larynx,  614 

Fig.  37.  Dr.  Hendrix's  tracheotomy  tube,  631. 

Figs.  38  —  40.  Dr.  O'Dwyer's  instruments,  A,  B,  C,  D,  for  intubation.  636 

Figs.  41  —  42.  Dr.  T.  F.  Rumbold's  spray-producing  instruments,  642 


LIST    OF    AUTHORS 


AND     WORKS     REFERRED     TO. 


Abeill*^. 

Acquapendente. 

Alaymo. 

Alexander. 

Albu. 

Allis. 

AndraL 

Andree,  ^fi>in 

Annandale. 

Archaml-ault. 

Aretseus. 

Asclepiades. 

Aiibrun,  Sr.,  Jr. 

Autenrieth. 

Avicenna. 

Ayers. 


Accetella. 

Adamson. 

Albers. 

Alibert. 

Albucasis. 

Amussat. 

Andre. 

Anger. 

Antyl  us. 

Archer,  Sr.,  Jr. 

Arron. 

Atlee. 

Aurelianus. 

Avenzoar. 

Axenftid. 


Babbington. 

Baillou. 

Baizeau. 

Balassa. 

Barbosa. 

Baron. 

Barry. 

Bartels. 

Barthez. 

Baudry. 

Baumbach. 

Bazin. 

Beau. 

Beaup. 

Becker. 

BecquereL 

Beherns. 


Bache. 

Bailly. 

Balzer. 

Barbeu. 

Bard. 

Barrier. 

Bartels,  Max. 

Bartholin. 

Bastion. 

Baudelocque. 

Bayley. 

Beau,  Verdeny. 

Beaupoil. 

Beclere. 

Behier. 

Bell. 

(14) 


LIST    OF    AUTHORS. 


XV 


Bellini. 

Bergius. 

Beringuir. 

Besnier. 

Bienfait. 

Bigelow. 

Binder. 

Bisnard. 

Bisson. 

Blache. 

Billroth. 

Blanclvt. 

Bland  1 1 . 

Bloom. 

Bogue,  R.  G. 

Boldyr .  w. 

Bond. 

Bonley. 

Borden. 

Borsieri. 

Bousedo. 

Boudillat 

Bourdon. 

Bousuge. 

Bowman. 

Boeckel,  E.  W. 

Brassavolo 

Branco. 

Bridger. 

Briddon 

Brown,  B. 

Broussais. 

Burgess. 

Burrow. 


Bergeron. 

Bernard,  CI. 

Bernheim. 

Bichat. 

Biermer. 

Billard. 

Bischof. 

Bissel. 

Bitdeheim. 

Blachez, 

Blanchetiere. 

Blondeau. 

Broeck. 

Boeckel. 

Boinet. 

Boiling. 

Bonisson. 

Bonnet. 

Boruscut. 

Bouchut 

Boudet. 

Bouillon  Lagrange. 

Bourgois. 

Bouvier. 

Braidwood. 

Brasch. 

Brenner. 

Bricheteau. 

Broncoli 

Brown-Sequard. 

Buchanan. 

Buhl. 

Burns. 

Buck. 


Cabot. 

Caillau. 

Calligari. 

Camlierlin. 

Carnevale. 

Carvalho. 

Cascalez. 

Casseri. 

Chantourelle. 

Charcot 

Chatard. 


Caldwell,  C.  P. 

Caillault. 

Calvet. 

Camuset. 

Caron. 

Casalds. 

Caspary. 

Chailly. 

Chapman. 

Chassaignac 

Chaussier. 


XVI 


LIST    OF    AUTHORS. 


Chavanne. 

Cheever. 

Cheyne. 

Cinni. 

Clemens. 

Coelius  Aurelianus. 

Cohnheim. 

Colin. 

Colson. 

Corcelle. 

Cook. 

Costi  has. 

Crawtord. 

Cruickshank. 


Daguillon. 

Damonette. 

Decker. 

De  la  Berge. 

Delacoux. 

Delthil. 

Demme. 

Deslandes. 

Ditzel. 

Double. 

Donders. 

Droste. 

Duch6. 

Duchenne. 

Duhomme. 

Dumontpallier. 

Durham. 

Duval. 

Diitersburg. 


Chedevergne. 

Chevalier. 

Chomel,  Sr. 

Classen. 

Cleveland. 

Cohen. 

Colden,  Cadwalader. 

Collin. 

Constantin. 

Cornil. 

Cortesio. 

Courty. 

Crequy. 

Curtis. 

D 

Damaschino. 

Daviot. 

Dehee. 

Delbert. 

Delens. 

Demarquay. 

Desault. 

Dickinson. 

D'Espine,  Sr.  Jr. 

Dobson. 

Dillie. 

Drysdale. 

Duchamp. 

Dufresse. 

Dujardin. 

Duplay. 

Durr. 

Dupuy. 


Easton. 

^gineta,  Paulus. 

Eisenschitz. 

Engstrom. 

Erb. 

Evans. 


Eberth. 
Eisenmann. 

Em  pis. 
^tius. 
Ebpine. 


Fabre. 
Faralli. 
Felix. 
Ferrand. 


Fagge. 
Fenger,  Chr. 
Fenner. 
Fergeot. 


LIST    OF    AUTHORS. 


XVll 


Fehrmann. 

Figueiras. 

Fischer. 

Flammarion. 

Fock. 

Fontheim. 

Foncher. 

Formad. 

Foster. 

Fourgeaud. 

Foville. 

Frcebelius. 


Ferrier. 

Finaz. 

Fisher. 

Fleishmann. 

FoUin. 

Foglio. 

Forest,  Peter. 

Foster. 

Fothergill. 

Fouris. 

Francisco. 

Fuller. 


Gairdner. 

Galentin. 

Garnier. 

Gavarret. 

Gendron. 

Gerlier. 

Germain. 

Gherli. 

Giacchi. 

Gibert. 

Gingiber. 

Gilette. 

Giron,  Sales. 

Giurleo. 

Goltwald. 

Gosselin. 

Goupil. 

Green. 

Graefe. 

Gregory. 

Grove. 

Grandvilliers. 

Gubler. 

Guersant. 

Guinnier. 

Guyet 

Habicot. 

Hachler. 

Hallenius. 

Hallier. 

Manner. 

Harless. 


Galen. 

Garengeot. 

Gaupp. 

Gay. 

Gee. 

Gerdy. 

Germe. 

Ghisi. 

Gibbon. 

Gigot- 

Gigon. 

Giovanni. 

Girtanner. 

Goddard. 

Gombault. 

Gottstein, 

Gree. 

Greenhow. 

Graf. 

Grisolle. 

Griinberg. 

Grandboulogne. 

Guerard. 

Guillemaut. 

Gustin. 

H 

Hache. 

Hagner. 

Haller. 

Hamilton. 

Harder. 

Hatin. 


XVUl 


LIST    OF    AUTHORS. 


Haughton. 

Heister. 

Henle. 

Henroz. 

Henoch. 

Heral. 

Herard. 

Herrera. 

Herville. 

Ilewson. 

Hillier. 

Hilton. 

Hirsch. 

Hoffmann. 

Home. 

Holmes. 

Howse. 

Hufeland. 

Hiillmann. 

Huxham. 


Hayem. 
Hemey. 
Hendrick. 
Hendrix. 
Henriques. 
Henriette. 
Heredia. 
Hervieux. 
Herpin. 
Heslop. 
Hippocrates. 
Hodge. 
Holden. 
Homolle. 
Hueter. 
Hunt,  E.  M. 
Hulke. 
Hutchinson. 
Huttenbrenner. 


Ingals,  E.  F. 
Isnard 


Isambert 


Jaccoud. 
Jacobi,  A. 
Jenner. 
Johnson. 
Juan  do  Soto. 
Jugand. 


Keen. 

Klaproth. 

Klee. 

Kohnemann. 

Korturn. 

Krackowitzer. 

Kiichenmeister. 


Jackson,  V. 
Jaffa,  Max. 
Jodin. 

Johnson,  H.  A. 
J  urine. 

K 

KeeteL 

Klebs. 

Kieser. 

Korting. 

Kraft-Ebing. 

Krishaber. 

Kiihn. 


Labadie  Lagrave. 

Laboulbene. 

Labat 

Lacaze. 

Laignez. 

Lallemand. 

Landeau. 


Labric. 
La  Board. 
Laennec. 
Lallement. 
Lancereaux. 
Lange. 


LIST   OF    AUTHORS. 


XIX 


Langenbeck. 

Larue. 

Latour. 

Lauton. 

Layaut6. 

Ledran. 

Le  Fort 

LegrOiX. 

Lespine. 

Letourneau. 

Lepine. 

Lepois. 

Leyden. 

Lionville. 

Loffler. 

Lorain. 

Louis. 

Lusitanus. 


McKenzie. 

Magne. 

Mair. 

Malichecq. 

Malouin. 

Marjolin. 

Marmisse. 

Marsb. 

Martin. 

Maunoir. 

Meigs. 

Menezes. 

Mesue. 

Michon. 

Millar. 

Minor. 

MiqueL 

Molloy. 

Morath. 

Morax. 

Monneret 

Monckton. 

Mounert. 

Muron. 


Napier. 
Nekton. 


Langbans. 

Lasegue. 

Laugier. 

Lavergne. 

Lecorche. 

Lee,  E.  W. 

Legros. 

Lemaire. 

Lespiau. 

Letzerich. 

Levis. 

Lewin. 

Lincoln. 

Littre. 

Loiseau. 

Loreau. 

Lunin. 

Liitz. 

M 

Malavicini. 

Maingault. 

Malgaigne. 

Maissonneuve. 

Rtaisord. 

Marchal. 

Marotte. 

Marteau  de  Grandvilliers. 

Maugin. 

Mazotto. 

Mellvain. 

Mercado. 

Michaelis. 

Middleton. 

Millard. 

Minowsky. 

Molendzinski. 

Mollereau. 

Moreau. 

Moriseau. 

Mortlake. 

Moiiremans. 

Moynier. 

Muller,  Max. 

N 

NasilofF. 
Neubauer. 


XX 


LIST    OF    AUTHORS. 


Neumann. 
Niemeyer. 
Nola. 
Nunez. 


O'Dwyer,  J. 

Oertel. 

Oppolzer. 

Ormerod. 

Oulmount 


Newcourt. 

NiveU 

Nonat- 

o 

Oelschlager. 

Onimus. 

Orillard. 

Otrobon. 

Ozanam. 


Packard. 

Paget. 

Pantaire. 

Parise. 

Paterson. 

Pean. 

Pelvet 

P6rat6. 

Perchant 

Perrin. 

Peter. 

Philippeaux. 

Picard. 

Pilcher,  L.  S. 

Pletzer. 

Polan. 

Prentis. 

Prosimi. 

Quinquaud. 

Raciborsky. 

Radcliff. 

Ranse. 

Ranvier. 

Rapin. 

Ravn. 

Raynaud. 

Rechou. 

Regnard. 

Reiffer. 

Reveil. 

Ridard. 

RillieL 


Page. 

Pancoast 

Parker,  R.  W. 

Parrot. 

Passavant. 

Pelletier  de  Chanbure. 

Pepper. 

Perier. 

Perron. 

Petit. 

Physick. 

Picot. 

Pinel. 

Plouviez. 

Potain. 

PouUet. 

Pouquet 

Prosper  Faucher. 

Q 

R 

Racle. 

Ranney,  S.  W. 

Ransom. 

Rapp. 

Raser. 

Rayer. 

Reboullet 

Regate. 

Reil. 

Revilliout 

Richardson. 

Richardson,  J.  R, 


\ 


Rindfleisch. 

Robert 

Robinson. 

Rodrigues. 

RokitanskL 

Rosati. 

Rosenthal. 

Rothe. 

Rouziez-Joly. 

Rudberg. 

Rumsey. 

Ruysch. 


•LIST   OF   AUTHORS. 

Rippley,  J,  H. 

Robin. 

Roche. 

Roger. 

Rollo. 

Rosen. 

Roser. 

Roux. 

Royer  Collard. 

Rumbold,  T.  F, 

Rush,  Benj. 


XXI 


Sebatier. 

Saint  Laurent 

Santy. 

S6e. 

Schobacher. 

Schrotter. 

Schiitz. 

Scoutetten. 

Seeligmiiller. 

Senator. 

Senf. 

Severinus. 

Signini. 

Smith,  Henry. 

Smith. 

Solomon. 

Starr. 

Steiner. 

Stephenson. 

Stoeber. 

Stoll. 

Strong,  A.  B. 

Sylva. 

Symwrhid. 


Saint  Germain. 
Santorio. 
Satterthwaite. 
See,  Germain. 
Schlier. 
Schmidt. 
Schulz. 
Schwilgu6. 
Sebastien. 
Sellerier. 
Sendler. 
Serlo. 
Sgambati. 
Simon,  Jules. 
Smith,  H.  H. 
Soglia. 
Soule. 
Squire. 
Stelzner. 
Steudener. 
Steppuhn. 
Stokes. 
Stolz. 


Tait. 

Tavignot. 

Teixeira. 

Thomas. 

Thompson. 

Tiedemann. 

Tilld. 

Tobanon. 


Tamajo. 

'J'ardieu. 

Tenderini. 

Thore. 

Thomson. 

Tillaux. 

Titanus. 

Tommasi. 


XXll 


LIST    OF    AUTHORS. 


Toulmouche. 

Traube. 

Trousseau. 


Uhde. 
Ullersperger, 


Townsend. 

Trideau. 

Tuefferd. 

u 

Uhlenburg. 
Underwood. 


Vallantine. 

Valerani. 

Van  Capelle. 

Velpeau. 

Vicq  d'  Azyr. 

Vidal. 

Villreal. 

Vogel. 

Vulpian. 

Voss. 


Wade- 
Wagner,  E. 
Warimann. 
Warmont 
Weber,  H. 
Wedel. 
Werner. 
iVhalbom. 
Wiedash. 
Wilson. 
Winkler. 
Wreden. 
Wynne. 


Valleix. 
Van  Bergen. 
Van  K5pl. 
Verneuil. 
Vieuseux. 
Vigla. 
Virchow. 
Voltolini. 
Von  Roth. 

w 

Wadel. 

Waldeyer. 

Warlomont. 

Waxham,  F.  E. 

Wecker. 

Weirus,  John. 

West. 

Wichmann. 

Wiederhoier. 

Wilke. 

Wood. 

Wundeilich. 


Zenker. 
Zorgo. 


Zobel. 
Zurkowski. 


INDEX. 


Abscess,            .            83,  289.  576,  647 

Anoesthetics, 

•      517 

Acids,            .            .            .            .70 

Angina, 

34,  74,  149,  416 

acetic,            .             .            71,  431 

benign. 

437 

boracic,     .             .             .            435 

croupal. 

35 

carbolic,         .             .            410, 433 

explosive. 

199 

chromic,              .            .                70 

gangrenous. 

54,  194 

citric,            .            .               71, 431 

maligna, 

35,  199,  437-8 

gallic,      .            .            .             409 

pestilential. 

38 

hydrochloric,              .            70,417 

Anorexia, 

212 

1                     lactic,        .            .          71,431,438 

Antimony,  sulph., 

40s 

'                      nitric,               .             .             70,417 

tartrate,     . 

395 

oxalic,         .             .                410, 425 

Antiphlogistics,     . 

•      389 

salicylic,            .            410,  4",  435 

Antispasmodics, 

453 

sulphuric,        .             .            70, 417 

Antiseptics, 

407,411,432 

Adenitis,      .            .             .81,  82, 644 

Apomorphia, 

450,  455 

Age,        .            .            .      350,377,445 

Aphonia, 

172 

Air,  in  veins,  death  from,     .            .     26 

Aphthae, 

279,  298,  399 

Albuminuria,     50,  124,  140,  et.  seq.,  200 

Apparatus,  see  Diphtheria. 

212,  294 

Asphyxia, 

496-98,  537 

Alcohol,     70,411-13,425,439,543,649 

Aspirator  tube, 

.      514,  550 

Alimentation,        .            .       8,  412,  571 

Astringents, 

424 

Alum,              .         73,  392, 419, 424, 438 

Atomizing, 

444 

Ammonia,               .             .          427, 444 

Auscultation, 

500-2 

Anatomy,  surgical,          .            i  et  seq. 

Autopsy, 

113 

Bacillus, 

373-4 

Bacteria, 

. 

57,66 

Balsamics, 

. 

37-8,  51,  392 

Beaty,  David  E.,  Jr., 

612 

Bite,  causing  diphth. 

. 

.      337 

Bladder, 

. 

124,  166 

Bleeding  in  diphth.. 

389 

Blisters, 

369, 

390,  440,  649 

Blood  in  diphth.. 

41, 

115,  121,390 

Borax,  .  .  .  424 

Bromate  of  potass.,     .  .  427 

Bromide  of  potass.,        .       72,427,438 

Bromine,    39,  70,  80,  406,  426,  432,  438, 

445,  449,  454 

Bronchitis  in  children,      .  231,  243 

capillary,       .  .  .        290 

pseudo-membranous,        .        642-4 

Broncho-pneumonia,  92-8,  232,  234,  502 


(23) 


XXIV 


INDEX. 


Calomel,     . 

73.  391 

Constipation, 

212 

Cartilage,  cricoid, 

see  Anatomy. 

Constitution,  medical 

e,           •            375 

thyroid, 

27 

Contagion, 

325 

Catarrh, 

283 

Contro-stimulants, 

5o>  435 

laryngitis. 

. 

Convulsions, 

161,620 

pneumonia. 

403 

Copaiba, 

401 

Cause,  see  Etiology 

Copper,  sulph.. 

418 

Catheterization  ol 

larynx,  446-8,  454, 635 

Corium,  lesions  of, 

59.  75 

Cauterization,  75, 

365,417-423,449.454 

Corrosive  sublimate. 

406 

Children, 

33,  38,  39 

Coryza, 

203,  241,  295,  641 

Chinolin, 

406 

Croup, 

439 

Chloral, 

433-34 

and  diphtheria,  identity,        .        48 

Chlorate,  see  Potass,  and  Sodium. 

cure  in. 

497 

Chorine  water, 

400 

diphtheritic, 

48,  62,  291,  363-s 

Cicatrization, 

•    593 

duration  of, 

76,  221,  225 

premature, 

594 

forms  of, 

217,  221 

Climate, 

.      320 

membrane, 

305 

Clots  in  heart, 

III,  116 

paroxysms  in, 

497 

Coal  tar. 

•     443 

periods  of. 

204-8,225,451-4 

Coffee,       . 

413.  437-8 

primary, 

201 

Cold,       . 

414 

secondary, 

504 

Cold  cream, 

.      580 

symptoms, 

203-9,  230 

Collapse, 

438 

treatment, 

497.  573 

Collodion, 

554,  562 

Cubebs, 

401,  402 

Complications, 

.    226,  230-8,  621,  646 

Cyanosis, 

501 

Conjunctivitis,  see  I  iphtheria. 


D 


Deaths  among  physicians. 

327 

Degeneration,  amyloic 

i, 

123 

fatty. 

127 

Diarrhoea, 

151 

Diphtheria: 

definition,     . 

. 

33  et  seq.,  52 

diagnosis. 

.      268  et  seq. 

etiology. 

303 

in  tracheotomy, 

. 

590 

ofanusj      40,  57, 

85. 

172,  258,  300 

of  bladder, 

124 

of  connective  tissue. 

83 

of  ear,              53, 

128 

251,  297,  644 

of  eye. 

. 

57,  127 

167. 

171 

247,  296,  644 

of  fauces. 

39,  416 

of  glands. 

81-2,  198,  644 

Diphtheria  0/  apparatus,  nervous,      125 

skin,  .  .  .         261 

German  view  of,  47,  58,  59,  360,  363 

a  parasitic  disease,         .         66,  372 

a  specific  disease, 

47,  51.  359,  369,  370 
conditions  favoring,  .  349 

conditions  unfavorable  to,  353 

contagiousness  of,  39,  326,  367 

course  of,  .  .  265 

duration  of,         .  .         265, 624 

following  other  diseases,  354 


forms  of, 

62,  131,  1F9,  387 

fungus  in, 

64,  372-4 

gangrene  in, 

77,  80-1 

incubation  of. 

355 

nature  of. 

359 

INDEX. 


XXV 


of  intestines, 

. 

85,    258 

of  larynx, 

282 

of  liver, 

. 

86 

of  lungs, 

. 

•     94 

of  mouth,            83, 

253-7, 

297,  646 

of  nose,  39,  41,86,  I 

29,  203, 

, 206,  295 

symptoms. 

• 

129,  192 

synonyms  of, 

. 

33 

of  apparatus : 

circulatory, 

. 

no 

digestive, 

83, 

253,  647 

genito-urinary. 

. 

124,  259 

glandular. 

81 -2; 

,  198,  644 

locomotor. 

128 

primary, 

. 

78,  130 

secondary, 

78, 

185-8,  353 

termination  of. 

. 

265 

transmission  of. 

325-6 

typhoid, 

• 

.        8s 

without  diphtheria,  62, 175,  282,  369 

Diphtherite,  .            .            45-7,  37 1 

Diphtheroid,  .             .              37° 

Drinks,  .             .            .            416 

Dropsy,  .            .            .         I44 

Dull  knife,  ...         9 

Dysphagia,  .             •            .          I97 

Dyspnoea,  .            .        35,213-16 


E 


Ear,  see  Diphtheria. 

Ecchemosis,         .  .  .         164 

Electricity,         .  .  166,  181-2 

Emboli,  .  .  .         106 

Emetics,         .  390-8, 435, 449, 452 

Emigration  of  blood  globules,  61-7,  73 
Emphysema,  .  105,  236,  550-4 

Endemics,  .  303  et  seq.,  380-2 

influence  of  other,  .  324 

Endo-carditis,         .  .      156  et  seq. 

Endocardium,  .  .  113 

Entrance  of  infectious  material  into 
the  system,  mode  of,  see  Trans- 
mission. 
Epidemics,  .  36-49,  304-324 


Epidemics,  influence  of  other,  324 

Epiglottis, 

Epistaxis,  .  .  .         154"^ 

Epithelium,  transformation  of,         58-69 
Eruptions,  40-1,  148  et  seq.,  212 

Erysipelas  in  tracheotomy,        .         581 
Eschar,  .  .  .         56,67-8 

Etiology,  ...  303 

Eustachian  tube,     .  .  S3,  253 

Expectorants,  .  •  4^4 

Experiments,  Curtis   and  S.,  Wood 

and  Formad,  .  339-41 

Extravasation  of  blood,  .  83 

Exudates,         .  .  .        72,403 

Eye,  see  Diphtheria. 


False  Membranes  : 
adherence  of, 
characteristics  of, 
chemical  characteristics  of, 

color,  .  .  41 

destruction  of, 
detachment  of, 
dimensions  of,     . 
expelled, 
extension  of, 
exudative  nature  of, 
forms  of,      41,  53,  62,  131,  I  { 
from  bronchi, 


False  membranes,  from  larynx,  57 

S4                nature  of,         .             .  .         67 

45-78                prevention  of,         .  .  389 

45-9,                 putrefaction  of,         .  .         363 

69,  70                structure  and  seat  of,  .         52-77 

I  53-55                theories  of,        .  .  58-62 

388  False  principle,            .  •        •    75 

76  Fascia,             .            .  .             5-10 

.     53  Fauces,     .          .             .  .             ^4 

35  Fever,            .            .  209,415,495 

74-5  Fibrin,  exudation  of,         .  61-9,  78 

67  Food,  see  Alimentation. 

I9,  387  Fumigation,          .            .  440, 443 

57 


XXVI 


INDEX. 


Gangjrene,  42,  56,  77-9,  81-3,  108,  152 


Gland,  thyroid,  isthmus,  2,9-11,18,21,527 


et  seq.,        .            .       171,  582 

623 

lymphatic. 

,       81 

Gargles,         .             .         416,423-4, 

435 

suppuration  of. 

647 

Geni to-urinary  organs,  see  Diphtheria. 

Glottis,  diameters  of. 

32 

Genius  epidemicus. 

375 

intubation  of, 

.      446, 635 

Germs, 

354 

Glycerine, 

•      70, 423 

German  views,  see  Diphtheria. 

Goat,  operation  on,         , 

459 

Gland,  thymus,         .            .            2,  19 

Grog, 

•       439 

H 


Haemorrhage,         154, 197, 199,  623,  647 

Heart,  clots  in. 

. 

117 

fatal,          ...               22 

Hemiplegia, 

•            • 

166 

into  trachea,  .             .            .18 

Herpes  labialis, 

. 

2S0 

in  tracheotomy,    18,  29,  30,  155,  537 

Herpetic  pharynpi    -, 

279, 

:62 

Haemostatics,           .             .          533,  543 

Hospital  gangrenj. 

. 

370 

forceps  of  Pean,      .               515,542 

Hygiene,  defecti\   , 

349, 

570 

Hearing,           .            .            .              168 

Hyoid  bone. 

. 

27 

Heart,         .             .             .          112,165 

Hyperinosis, 

121, 

145 

Ice,        .  .  .  408, 415-16 

Identity  of  all  forms  of  diphtheria,       68 
Illumination,        .  .  .         516 

Impotence,         .  .  .  166 

Incubation,  .  .         315,  355-8 

Indications  for  treatment,  .  387 

Infection,         .  •        359,  363,  37° 

deaths  from   in  physicians,  327 

Inflation  tube,  .  .  550-3 

Inhalations,         .  .  .         443 

Injections,  .  .  .         445 

Inoculability,         .  .       326  et  seq. 


Inoculability,  accidental. 

•       331-3 

by  false  membranes, 

337 

Insufflation, 

. 

423-5,  440 

Intelligence, 

. 

169 

Intestines, 

. 

.     85,258 

Intubation, 

. 

446,  635 

Iodine, 

70, 

401,  410,  441 

Ipecac, 

. 

450 

Iron, 

414 

perchloride  of. 

7 

:,  406-7,  418 

Irrigation, 

. 

•      438 

Isolation, 

• 

652 

Jaborandi, 
Jews, 


405        Jugular  veins, 
33 


16 


K 


Kermes  mineral. 
Kidneys, 


405 
122,  145-6 


Kidneys,  loops  of  Henle, 


123 


INDEX. 


XXVll 


Labarraque's  sol. 

409-14,  433 

Leeches,           .            .            .            390 

Lactic  acid,  see  Acid. 

Lemon  juice,         .            .            .       430 

Landmarks,  suigical, 

I 

Leptothrix  buccalis,             .            .       66 

Laryngeal  diphtheria. 

282 

Lesions,  primary,  secuiula.y,         .         52 

lesions. 

625-6 

Leucocytes,         ...          78 

Laryngitis, 

.          283 

Light,          ....     516 

Laryngocentesis, 

459 

Lime,  saccharate,         .             .            428 

Laryngoscope, 

.    609 

water,           399,  427,  438,  444-5,  454 

Laryngotomy, 

34,  460 

"  Line  of  safety,"           .             .         3,  26 

Laryngo-tracheotoni) , 

10,  29 

Listerine,              .             .             .        435 

Larynx, 

27,  87,  170 

Localization,             .             315,  376,  416 

foreign  bodies  in. 

.     289 

Locomotor  ataxia,            .             .         303 

intubation  of. 

•      635-40 

Lymphatics,            .            .            .81 

M 


Malignant  pustule,  .  .        361 

Martyrology,  .  .  .     327 

Measles,  185,  238,  254,  495,  504 

Mediastinum,  .  .  109 

Medulla,  .  .  .         169 

Membrane,  see  False  Membrane. 

mucous,  .  .  -77 

serous,        ...  62 


Mercury, 


Mercury,  salts  of, 

Micro-organisms, 

Milk, 

Morbus  strangulatorius, 

Mortality,  see  Statisiics 

Mortification, 

Motility, 

Mucin, 


.  319,  406,  432,  442         Muguet, 


N 


73 

51,  57,  64-6 

408 

38 

So 

163,  166 

69,  76 

279 


Necrosis,         .  .  .67,  76 

Nephritis  (see  also  Kidneys),  58 

Nervous  system,  see  Paralysis,  and 
Diphtheria  of  apparatus. 


Neurin,  .  .  .  644 

Nitrate  of  silver,  .  .  73 

Nurses,  trained,  see  Tracheotomy. 
Nutrition,  see  Alimentation. 


CEdema, 

glottidis, 
pulmonary, 

CEsophagus, 


109,  124,  144,  156 

82,  88,  92,  241,  286 

237 


Ontology, 

Origin, 

Oxalic  acid,  see  Acii 


75.  84,  554        Oysters, 


407 
303 

412 


Palate,        .  37-9,  79,  84,  161,  179 

Papayotin  (papaine),        .  .      644 

Paralysis,  37-9,  40-3,    51,  89,   126,  16), 


161  et  seq.,     . 
Parasites,  see  Micro-organisms. 


302,  650 


Pharyngitis,  herpetic. 

279,  362 

Pilcher,  Dr.  L.  S., 

504 

Pilocarpine, 

. 

Plasma, 

120 

Pleurisy, 

.       103,  236 

XXVUl 


INDEX. 


Paresis,  see  Paralysis. 
Pathological,  see  Anatomy. 

physiology, 
Penis, 

Pepsin,        .  .  .  . 

Pericardium, 
Pharyngitis,       175,  189,  272  et  seq 

benign, 


diphtheritic, 
duration  of, 


73.  213 
124 

112 
366 
190 
193,272 
197 


Pneumonia,  broncho-,  92,  232,  502 

croupal,  58,  lOl,  403,  503,  622,  649 


pleuro- 
Polypus  of  larynx, 
Position  of  patient. 
Prevention, 
Prize, 
Prognosis, 
Prophylaxis. 


104 

613 

515.650 

.      239,  652 

44,  397.  460 

.    375.377 

239,  652-6 


Quinine, 


412,437-8,455 


R 


Railroads, 

320 

Resorcine, 

Rectum, 

165 

Respiration, 

Recurrence  (recedive). 

265,  377 

Rete  mucosum, 

Relapse, 

315 

Rhinoscopic, 

Remedies,  numerous, 

4" 

Rubeola, 

406 

•    244 

.    81 

206, 295 

80 


Salicylic  acid,  see  Acid. 

Salivation,  .  .  292,  392 

Scarlatina,  124,  144,  149,  186-8,  239, 

354,  377.  495.  504 
Scoutteten,  .  .  481,448 

Season,         .  .         316,  320-1,  378 

Self  limitation, 

."-enega,  .  .  •  404 

Sensation,         .  .  .  167 

Sepia  blood,  see  Blood. 
Sequelae,       .  .  •         240,  379 

Sex,         .             .  .       351.377.492 

Spasm,        .            .  .            .161 

Skin,  diphtheria  of,  .            .      646 
Skin,  mobility  of  in  tracheotomy,      4,  5 

Small-pox,         .  .             .           504 

Smell,           .             -  .            .168 
Sodium,  benzoate, 

bi-carbonate,  .       3934, 427 

chlorate  of,     .  .     72,  426,  430 

chloride  of,  .             .              73 

hypobromite,  .          .             73 

Soda,  caustic,  .            .            418 


Spasm  of  glottis, 

of  larynx, 
Speech,       . 
Specifics, 
Spray, 
Statistics,   . 
Steam, 
Sternutatories, 


.      289,  617 

421,  428 

.      168 

50,411,416,443 

.       445,  642 

380,  et  seq.,  456,  et  seq. 

.      441 

452 


Stimulants,  see  Alcohol, 
Stomach,  .  .         85-6,  15 1-7 

Stomatitis,     .  84,  257,  298,  392,  429 

Strabismus,         ...  39 


Stricture,  of  larynx, 
of  pharynx, 
of  trachea. 

Strychnia, 

Suffocation, 

Sulphur, 

Sulphites, 

Swabbing  of  larynx, 

Symptoms, 

Syncope, 

Syphilis, 


.     82 

82 

.      93, 607-8 

•     35. 47 

407,  424,  438 

410 

443 
129,  192,  201 

537 
33^> 377 


INDEX. 

T 

Table,  operating, 

515 

Tannin,     . 

.  424,438,454 

Tartar  emetic, 

•    395.449 

Taste, 

.       168 

Teeth, 

•     35,  392 

Temperature, 

209-11,  502,  571 

Temperament, 

•    352,378 

Thermo-cautery, 

30 

Throat, 

416 

Thrombosis, 

116  etseq.,  158 

Tirage, 

206 

Tonics, 

413,  439,  455 

Tongue, 

84 

Tonsillitis, 

273,  422 

Trachea,  see  also  Surg.  Anatomy,  90 
aspirator,  .  .  550 

collapse  of  walls  of    .  .      563 

diameters  of,        .  .        31,  32 

fistula  of,        .  .  .619 

impertect  incisions  of,  .  544-7 
movements  of,      .  .  2,  27 

polypus  of,     •  .       93, 608-16 

retraction  of,         .  .  29 

rings  of,  .  12, 29,  92, 489 

ulceration  of,  .  51,  91-3,  601-7 
Tracheotomy,       .... 

34,  38, 

42,  47,  50,  451.  458,  et  seq.,  638 
age,  .  .         481, 488-92 

accidents  of,     . 

497,  525,  537, 547.  555. 575.  et  seq. 
after-treatment  of,        .  .     557 

bloodless,  .  .  30 

causes  which  influence  the  results 

of,  .  .  .  487 

causes  which  prevent,  568,  624-34 
dangers  and  difficulties  in,  i,  2,  19, 

26, 30,  489,  497-8,  525,  544-7,  551; 
day-light  for,  .  500,  516 


XXIX 


dilators  in,        .  .       508,  513 

dressing  after,         5i3-'4.  525,  5^0 
early  operation,  .  495 

eruptive  fevers,  .  •    495 

final  removal  of  cannula  in, 

565,  et  seq. 

gangrene  in,  .  582, 623 

hemorrhage  in  and   treatment    of, 

537-44,621 

indications  for,  and  contra-,  495-506 

in  extremis,  .  .        496-8 

land-marks  in,  .       I,  2,  528-30 

measles,      .  .  495»  5°4 

methods,  "high,  low,   crico-trache- 

otomy,"     .  .  519,  et  seq. 

period  for,        .  .  495"9 

pioneers  of,  .  .  460 

previous  health,  .  .    492 

"         treatment,  .  494 

preparation  for,  .  506-13 

process,  slow,  and  rapid,        527-34 

season  of  year,  .  .     494 

sequelae  of,  .  .  556 

statistics  of,  50  et   seq  ,471  et  seq. 

steps  of,  .  .  .     520 

temperament,  .  •  493 

tenaculum,  use  of  in,       .      528-30 

thermic,  .  .  534-37 

tubes,         .  32.  5 »o,  513,  634 

without  dilators,  .         508,  513 

"         tubes,      .  .  513 

Transmission  ol  diphtheria,         .  . 

325-6,   345,   et    seq. 

Treatment  of  diptheria,      387,  416,  573 

period  for,  .  .  451 

Tubercle,  cricoid,  .  528-30 

Tuberculosis,  187,  303,  377,  505 

Turpentine,  .  .  406, 443 

Typhoid  fever,  .  .    377,405 


u 


Urine, 


183-4,  195        Ulceration,      35, 77-80,  88,  92,  579,  601 


XXX  INDEX. 

V 

Vibrios,           .           .            •             57               variations  of,        .           .         2-17 

Veins,  plexus  of  in  neck,              .     1-16        Vichy  water,  .            ,         392, 427 

innominate,           .            .             21        Vomiting,  .            .               152,212 

thyroid,           .            .            .13        Ventilation,  •            .            -571 

Whooping  cough,            186-7, 240.  S04        Wine,             .  .            413,  437-8 

z 

Zinc,  sulph.,             •           •             45°        Zymotic,  ...            51 


SUMMARY  OF  A  REPORT  OF  A  CAST. 

BY  DR.  H.  GRAFF,  OF  EAU  CLAIRE,  WISCONSIN. 
[Ill  stration  opposite  Frontispiece.] 

Case.  A  girl  aged  i6  years  was  taken  sick  on  October  lO, 
1883.  The  doctor  was  called  October  14.  Found  the  patient 
with  fever  and  pain  in  the  throat,  and  considerable  swelling 
about  the  neck.  Both  tonsils  were  covered  with  a  greyish 
membrane.  Diagnosis :  Diphtheria,  of  which  there  was  a 
"violent  epidemic"  prevailing  in  the  locality.  On  the  15th, 
condition  about  the  same.  On  i6th,  the  doctor  was  called 
early  and  found  the  patient  suffering  most  "violent  dyspnoea 
and  slight  asphyxia."  This  condition  had  been  growing  worse 
during  the  night.  At  noon  when  making  his  next  visit  he 
found  the  patient  sleeping,  her  respiration  almost  normal,  and 
the  surface  bathed  with  perspiration.  He  had  at  the  last  visit 
given  her  0.04  (Ys  gr.)  of  sulphide  of  calcium.  About  an  hour 
after  the  previous  visit  the  patient  had  occasion  to  get  up  and 
was  siezed  with  a  violent  paroxysm  of  coughing,  and  after  ex- 
treme efforts  she  shot  up  a  "white  rag"  which  the  mother 
showed  him  in  the  spitoon.  This  ivhite  rag — the  false  mem- 
brane— the  doctor  took  to  the  office,  and  on  examination  it 
was  found  to  be  a  complete  cast  of  the  trachea  and  bronchial 
tubes  down  to  the  smaller  ramifications,  and  all  in  one  piece. 
See  frontispiece. 

A  photograph  was  taken  of  it  while  fresh,  and  then  the 
specimen  was  dried  and  varnished.  The  doctor  has  it  in  his 
possession.  The  relief  was  of  short  duration ;  after  about 
eight  hours  dyspnoea  returned,  and  she  gradually  grew  worse 
until  she  died,  at  9  o'clock  the  next  morning.  No  post  mor- 
tem examination  could  be  obtained.  How  much  this  is  like 
the  first  case/eported  by  Dr.  Stephenson,  of  Leesville,  O.,  only 
a  more  perfect  specimen  (p.  305).  Also  the  case  reported  by 
Marteau  de  Grandvilliers  more  than  a  century  ago  ;  as  well  as 
cases  described  by  the  early  writers,  as  Galen,  who  saw  a  pa- 
tient expel  a  thick  viscid  membrane  supposed  to  be  the  epi- 
glottis. 


[SURGICAL    ANATOMY    OF    THE    PRE -TRACHEAL 

REGION    WITH    SPECIAL     REFERENCE    TO 

TRACHEOTOMY     IN     CHILDREN. 

Without  desiring  to  magnify  the  difficulties  which  may  be 
met  with  in  the  operation  of  opening  the  trachea  for  the  reHef 
of  dyspnoea  in  croup,  but  with  a  purpose  to  give  them  their 
true  weight  and  to  aid  in  recommending  measures  by  which 
they  may  be  avoided  or  surmounted,  I  have  deemed  it  not  un- 
important to  add  to  what^has  been  said  by  the  author,  even  at 
the  risk  of  repetition,  some  remarks  and  illustrations  which 
may  be  of  service  (at  least  to  beginners)  in  this  operation. 
Having  heard  remarks  from  those  who  may  have  operated 
once  or  twice  or,  at  most,  but  a  few  times,  indicating  their 
opinion  of  the  operation  for  croup,  even  in  quite  young  chil- 
dren, as  being  rather  a  simple  operation  and  not  dangerous,  I 
feel  bound  to  say  that,  in  my  opinion,  it  is  one  of  the  most  un- 
pleasant, if  not  dangerous,  as  met  with  binder  the  usual  circum- 
stances, of  all  the  operations  which  the  surgeon  is  called  upon 
to  perform.  In  other  words,  I  entirely  agree  with  Dr.  John  H. 
Ripley,  of  New  York,  that  there  are  probably  more  patients 
die  on  the  table  in  or  after  the  operation  of  tracheotomy  for 
croup  than  in  any  other  established  operation  in  surgery.  I 
would  myself  prefer  to  amputate  at  the  hip-joint,  or  perform 
ovariotomy ;  though  I  have  never  refused  the  operation,  but, 
under  proper  circumstances,  always  urge  it.  A  few  sections 
(25,  26  and  27)  from  Holden's  excellent  work  on  "  Land-Marks, 
Medical  and  Surgical,"  will  here  be  inserted : 

25.  Cricoid  Cartilage. — The  projection  of  the  cricoid  carti- 
lage is  a  point  of  great  interest  to  the  surgeon,  because  it  is  his 
chief  guide  in  opening  the  air  passages,  and  can  always  be  felt 
even  in  infants,  however  young  or  fat.  [In  some  cases  I  have 
found  it  very  obscure  indeed].     It  corresponds  to  the   interval 

(I) 


2  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

between  the  fifth  and  sixth  cervical  vertebrae.  The  commence- 
ment of  the  oesophagus  Hes  behind  it ;  here,  therefore,  a  for- 
eign substance  too  large  to  be  swallowed  would  probably 
lodge,  and  might  be  felt  externally.  Again,  a  transverse  line 
drawn  from  the  cricoid  cartilage  horizontally  across  the  neck 
would  pass  over  the  spot  where  the  omo-hyoid  crosses  the 
common  carotid.  Just  above  this  spot  is  the  most  convenient 
place  for  tying  the  artery. 

26.  Those  who  have  not  directed  their  attention  to  the  sub- 
ject are  hardly  aware  what  a  little  distance  there  is  between 
the  cricoid  cartilage  and  the  upper  part  of  the  sternum.  In  a 
person  of  the  average  height,  sitting  with  the  neck  in  an  easy 
position,  the  distance  is  barely  one  inch  and  a  half.  When  the 
neck  is  well  stretched,  about  three-quarters  of  an  inch  more 
is  gained  [1V2+V4  in. =2^/4].  Thus,  we  have  (generally)  not 
more  than  seven  or  eight  rings  of  the  trachea  above  the  stern- 
um. None  of  these  rings  can  be  felt  externally.  The  second, 
third  and  fourth  are  covered  by  the  isthmus  of  the  thyroid 
gland.  The  trachea,  it  should  be  remembered,  recedes  from 
the  surface  more  and  more  as  it  descends,  so  that,  just  above 
the  sternum,  in  a  short,  fat-necked  adult,  the  front  of  the  tra- 
chea would  be  quite  one  inch  and  a  half  from  the  skin. 

27.  Trachea. — In  the  dead  subject  nothing  is  more  easy 
than  to  open  the  trachea ;  in  the  living,  this  operation  may  be 
attended  with  the  greatest  difficulties.  In  urgent  dyspnoea 
you  must  expect  to  find  the  patient  with  his  head  bent  for- 
ward, and  the  chin  dropped,  so  as  to  relax  as  much  as  possi- 
ble the  parts.  On  raising  his  head,  a  paroxysm  of  dyspnoea 
is  almost  sure  to  come  on,  threatening  instant  suffocation. 
The  elevator  and  depressor  muscles  draw  the  trachea  and  lar- 
ynx up  and  down  with  a  rapidity  and  a  force  which  may  bring 
the  cricoid  cartilage  within  half  an  inch  of  the  sternum.  The 
great  thyroid  veins  which  descend  in  front  of  the  trachea  are 
sure  to  be  distended.  There  may  be  a  middle  thyroid  artery. 
In  children  the  lobes  of  the  thymus  may  extend  up  in  front  of 
the  trachea,  and  the  left  vena  innominata  may  cross  it  unusu- 
ally high.     Thus  the  air-tube   may  be   covered  by   important 


TRACHEOTOMY    IN    CHILDREN,  3 

parts  which  ought  not  to  be  cut.  Considering  all  these  possi- 
ble complications,  the  least  difficult  and  the  best  mode  of  pro- 
ceeding is  to  open  the  trachea  just  below  the  cricoid  cartilage, 
and  if  more  room  be  requisite,  to  pull  down  the  isthmus  of  the 
thyroid  gland  or,  in  children,  to  divide  the  cricoid  itself.  It  is 
important  that  all  the  incisions  be  made  strictly  in  the  middle 
line,  the  "  line  of  safety." 

With  the  free  and  generous  consent  of  my  friend.  Dr.  L.  S. 
Pilcher,  of  Brooklyn,  N.  Y.,  I  shall  make  use  of  the  illustra- 
tions and  much  of  the  text  of  his  able  article  in  "Annals  of 
Anatomy  and  Surgery,"  April,  1881.  The  description  of  the 
plates  scarcely  admits  of  abbreviation,  hence  I  shall  insert 
the  most  of  it  entire,  and  will  make  free  use  of  the  main  por- 
tion of  the  article.  The  colored  plate  I  have  had  prepared 
expressly  for  this  part  of  the  work.  It  is  enlarged  from  Gray,, 
with  a  few  changes. 

That  part  of  the  neck  interesting  to  the  surgeon  in  the  op- 
eration of  tracheotomy  is  comprised  between  the  hyoid  bone 
above,  the  sternum  below,  and  the  sterno-cleido-mastoid  and 
anterior  belly  of  the  omo-hyoid  muscle  on  each  side.  The 
space  thus  bounded  has  been  designated  by  Dr.  L.  S.  Pilcher,. 
"  The  Anterior  Median  Region  of  the  Neck." 


DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 


FIG.   I  a.       THE  VESSELS    OF    THE    PRETRACHEAL    SPACE,  NATURAL 
SIZE FROM  A  CHILD  OF  3  YEARS. 

A,  Great  transverse  vein.  BB,  Internal  jugular  veins.  CCC,  Inferior  thyroid 
venus  plexus.  D,  Lateral  thyroid  vein.  E,  Left  common  carotid  arteiy.  F,  Isthmus 
of  the  thyroid  gland.  G,  Crico-thyroid  space  with  arter>'.  H,  Superior  thyroid  ar- 
tery with  accompanying  vein. 

The  structures  met  with  in  this  operation  are : 
The  ski)i  in  this  region  is  thin,  soft  and  very  movable ;  in- 
deed, so  great  is  the  mobiHty  that  it  is  well  for  the  operator, 
unless  his  experience  in  the  operation  under  consideration  is 
large,  to  mark  out  on  the  skin  the  line  of  incision  before  com- 
mencing the  operation,  otherwise,  in  the  end,  the  lines  of  in- 
cision in  the  skin  and  in  the  muscles  may  be  found  not  to  cor- 


TRACHEOTOMY    IN    CHILDREN. 


respond.     While  the  first  division  of  tissue  is  being  made,  the 
skin  should  be  either  drawn  tense,  or  it  may  be  transfixed. 


FIG.    I  b.       THE  DEEP  LAYER  OF  THE  SUPERFICIAL  FASCIA  WITH  THE 
ANTERIOR  JUGULAR  VENOUS  PLEXUS — TYPICAL  ARRANGEMENT. 

The  Siipe^'ficial  Fascia  of  this  region  may  be  separated  into 
the  superficial  and  the  deep  layers.  The  former,  together  with 
the  skin,  forms  \h&  first  layer  in  this  region. — Pilcher.  In  the 
latter  are  to  be  found  spread-out  nerve  filaments  and  arterial 
twigs  of  no  special  importance ;  but  between  this  layer  and 
the  deep  cervical  fascia  lie  the  venous  trunks  of  the  anterior 
jugular  plexus.  Fig.  i  a  gives  the  most  frequent  arrangement, 
from  which  there  are  very  frequent  variations.  "  In  this  the 
venous  radicles  below  the  chin  with,  perhaps,  communicating 
branches  from  the  facial,  or  external  jugular,  unite  to  form 
two  trunks  which  run  downwards  parallel  with   each   other,  a 


6  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

little  to  the  outside  of  the  median  line  on  each  side ;  as  they 
approach  the  sternum  they  sink  beneath  the  deep  cervical  fas- 
cia, and  each,  turning  sharply  outwards,  passes  behind  the 
sterno-cleido-mastoid,  along  the  upper  margin  of  the  clavicle, 
to  the  outer  border  of  the  muscle,  where,  in  common  with  the 
external  jugular,  it  empties  into  the  sub-clavian.  A  transverse 
branch  unites  the  two  lateral  trunks  above ;  and  again,  just 
above  the  sternum,  under  the  deep  fascia,  a  similar  communi- 
cating transverse  branch  is  usual. 

"A  frequent  variation  is  the  presence  of  but  one  trunk,  which 
lies  directly  in  the  median  line  as  shown  in  Fig.  2,  and  again 
at  A,  on  Fig.  i6. 


FIG.  2.       SINGLE  MEDIAN  ANTERIOR  VEIN. 

'Other  arrangements  are  shown  in  Figures  3  and  4,  in  which 


FIG.  3.   ANTERIOR  JUGULAR 
VENOUS  FLEXUS. 


FIG.  4.   ANTERIOR  JUGULAR 
VENOUS  FLEXUS. 


TRACHEOTOMY    IN    CHILDREN.  7 

the  absence  of  one  of  the  usual  lateral  trunks  is  compensated 
for  by  a  large  obliquely  transverse  branch  which  comes  from 
the  external  jugular  and  crosses  the  neck  in  its  lower  third  to 
join  the  lateral  anterior  jugular  of  the  other  side."  Some  of 
these  trunks  may  be  divided  either  in  the  early  or  in  the  latter 
part  of  the  operation,  and  may  produce  very  embarrassing  or 
even  dangerous  haemorrhage.  "  In  the  median  line  the  deep 
layer  of  the  superficial  fascia  is  practically  blended  with  the 
deep  fascia  proper,  the  points  where  they  are  separated  by  the 
anterior  jugular  venous  plexus  alone  excepted.  This  deep 
fascia,  which  is  the  cervical  aponeurosis  proper,  is  of  great  in- 
terest and  importance  in  this  region.  Stretched  from  the 
hyoid  bone,  over  the  thyroid  cartilage  above,  to  the  upper 
border  of  the  sternum  below,  this  aponeurosis,  at  a  point  mid- 
way between  the  cricoid  cartilage  and  the  sternal  notch,  di- 
vides into  two  well-marked,  dense  fibrous  layers,  the  more  su- 
perficial of  which  is  inserted  into  the  anterior  border  of  the 
sternum,  and  the  deeper  one  into  its  posterior  border,  the  in- 
terval between  them  being  filled  by  connective  tissue  and 
fat." 

The  fact  of  this  union  or  separation  should  be  borne  in 
mind,  else  embarrassment  may  arise  in  the  operation  by  sup- 
posing that  both  layers  have  been  divided  when  it  may  be 
only  one  has  been.  The  two  layers  should  both  be  nicked, 
then  the  director  will  pass  easily  beneath,  either  upwards  or 
downwards,  and  the  venous  trunks  may  thus  be  frequently 
avoided. 


DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 


FIG. 


ANTERIOR  CERVICAL  MUSCLES. 


a,  Sterno-cleido-mastoid.      l>,   omo-hyoid.      r,    sterno-hyoid.       d,   stemo-thyroid. 
h,  hyoid  bone. 

"This  aponeurosis,  with' the  deeper  layer  of  the  superficial 
fascia,  constitutes  the  second  layer,  and  their  incision  the  second 
step  in  the  operation  of  tracheotomy." — Pilcher.  The  next 
structures  met  with  are  the  sterno-hyoid  and  the  sterno-thyroid 
muscles  on  each  side.  They  are  intimately  connected  by 
their  sheaths  to  the  cervical  aponeurosis;  their  inner  margins, 
varying  as  to  proximity,  are  connected  by  a  more  or  less  dense 
layer  of  fibrous  tissue.  These,  with  the  connective  tissue 
layer,  form  the  tJiii'd  layer  to  be  recognized  in  the  operation. 
The  dividing  line  between  these  muscles  may  not  always  be 
readily  distinguished.  By  rendering  the  parts  tense  in  the 
median  line,  the  separation  may  be   readily  made   by  using  a 


TRACHEOTOMY    IN    CHILDREN. 


blunt-pointed  or  dull  knife.  The  separation  having  been  ef- 
fected, tJie  pre-tracheal  space  proper  is  opened  ;  and  its  struct- 
ures form  thQ  fo2(rth  layer. 

"  This  space  is  divided  into  two  nearly  equal  parts  by  the 
isthmus  of  the  thyroid  gland,  which  parts  differ  greatly  as  to 
their  accessibility,  and  as  to  the  possible  complications  with 
which  operations  in  them  may  be  accompanied." 


FIG.   6.       PRETRACHEAL     SPACE     WITH     TYPICAL    ARRANGEMENT    OF 

VESSELS  AND  OF  THYROID  GLAND FROM  NATURE. 

A,  Great  transverse  vein.  BB,  Internal  jugular  veins.  C,  Median  inferior  thyroid 
vein.  D,  Innominate  artery.  E,  Left  common  carotid  artery.  F,  Thyroid  isthmus. 
G,  Crico-thyroid  space  and  arteiy.  H,  Superior  thyroid  artery.  I,  Lateral  inferior 
thyroid  vein. 


lO  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

"  The  inter-muscular  connective  tissue  layer  at  the  level  of 
the  isthmus  of  the  thyroid  is  closely  applied  upon  its  anterior 
surface,  and  furnishes  a  sheath  for  it  which  is  reflected  outward 
upon  the  lateral  lobes  and  affords  a  distinct  fibrous  envelope 
for  the  whole  gland."  It  also  unites  intimately  with  the 
sheath  of  connective  tissue  surrounding  the  trachea  ;  thus  con- 
necting the  two  organs  closely,  and  securing  their  conjoint 
movements.  By  separating  the  muscles  above  the  isthmus  we 
expose  the  thyroid  and  cricoid  cartilages.  "  Between  the  isth- 
mus and  the  latter  there  is  found  the  fascia  laryngo-tJiyroidea 
of  Hueter,  which  covers  the  trachea.  By  tearing  through 
this  fascia  transversely  until  the  first  ring  of  the  trachea  is  ex- 
posed, it  is  quite  easy  to  get  under  the  fascia  thyro-trachealis 
and  separate  the  isthmus  from  the  trachea  to  an  extent  suffic- 
ient to  permit  its  depression  so  far  as  to  expose  the  two  rings 
next  below."  Thus  tracheotomy  may  be  performed  above  the 
isthmus  without  encroaching  upon  the  cricoid  cartilage. 

If  more  room  should  be  required  the  cricoid  may  be  divided 
— laryngo-tracheotomy — the  dilatation  of  this  cartilage  in  the 
very  young  being  easily  accomplished. 

"The  structures  just  described,  including  the  thyroid  isth- 
mus, the  fascia  laryngo-thyroidea,  and  the  fascia  thyro-trach- 
ealis, compose  \h&  fourth  and  final  layer  into  which  the  su- 
perior pretracheal  structures  are  practically  divisible  —  the 
identification  and  removal  of  which  in  their  order  is  desirable. 
The  isthmus  of  the  thyroid  may  vary  greatly  in  volume.  The 
series  of  drawings  from  my  own  dissections,  which  illustrate 
the  anatomy  of  the  pretracheal  space.  Figures  6,  8,  9,  10,  11, 
12,  13,  14  and  15,  show  the  ordinary  variations  in  the  shape 
and  volume  of  the  isthmus.  In  one  of  my  operations  (Mary 
Sandford,  aet.  10  years)  there  was  present  a  very  broad  isth- 
mus   which    descended    nearly   to    the    upper  border   of  the 


TRACHEOTOMY    IN    CHILDREN. 


II 


FIG.  7.       LARYNX  AND  TRACHEA    OF    CHILD    OF    6  YEARS,  NATURAL 

SIZE,  ISTHMUS  ABSENT.       PYRAMID  OF  LALOUETTE  ON 

LEFT  SIDE. 


sternum.  By  holding  it  up  with  a  retractor,  I  was,  however, 
enabled  to  expose  the  trachea  and  incise  it  without  other 
complications.  In  a  recent  dissection  upon  the  body  of  a  girl, 
set.  6  years,  I  found  the  isthmus  entirely  wanting,  an  interval 
of  four  millimetres  separating  the  inner  borders  of  the  lateral 
lobes  in  front  of  the  trachea ;  from  the  superior  border  of  the 
left  lobe  there  is  prolonged  upwards  and  inwards  a  glandular 
slip  which  is  attached  to  the  body  of  the  hyoid  bone — the 
pyramid  of  Lalouette.  Fig.  7  shows  the  preparation  the  nat- 
ural size.     Usually  the  second,  third  and   fourth   rings   of  the 


12 


DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 


trachea  are  covered  by  the  isthmus.  The  vascularity  of  the 
isthmus  is  also  the  subject  of  great  variations.  In  addition  to 
the  vascular  network  in  its  interior,  there  is  usually  a  small 
arterial  loop  which  runs  along  its  upper  border  (See  H,  Fig.  6) 
connecting  the  superior  thyroid  arteries  on  either  side.  This 
may  be  of  considerable  size,  as  in  the  case  from  which  the 
drawing  that  constitutes  the  Fig.  i  a  was  taken,  and  as  again 
in  Fig.  8. 


FIG.  8.   TRANSVERSE  ANASTOMOSING  SUPERIOR  THYROID  ARTERY 

OF  LARGE  SIZE  ;  ABNORMAL  COURSE  OF  THE_^CRICO- 

THYROID  BRANCH. 

D,  Innominate  arteiy.      E,  Left  carotid  artery.     F,  Isthmus  of  the  thyroid  gland. 
G,  Crico-thyroid  space.     HH,  Superior  thyroid  arteries. 

"An  abnormal  course  of  the  superior  thyroid  artery,  which 
may  give  to  the  isthmus  arterial  branches  of  unusual  size,  is 
not  usual.      In  the   case   represented   in   Fig.  9,  the   anterior 


TRACHEOTOMY    IN    CHILDREN.  1 3 

trunk  of  the  superior  thyroid  artery  passes  as  a  vessel  of  con-- 
siderable  size  to  the  middle  of  the  isthmus,  where  it  breaks  up 
into  branches  of  distribution.  A  transverse  vein,  the  compan- 
ion of  the  transverse  artery,  is  regularly  present  at  the  supe- 
rior border  of  the   isthmus,   inosculating  on   either  side  with 


FIG.  9.       IRREGULAR  COURSE  OF  THE    SUPERIOR    THYROID    ARTERY 
WITH  ANOMALOUS  SUB-HYOID  AND  CRICO-THYROID  BRANCHES. 

the  superior  thyroid  veins.  (See  Figure  i  a,  and  Figures  lO, 
II,  13  and  15).  The  arrangement  is  more  as  if  the  superior 
veins  from  the  upper  border  of  either  lobe  had  met  and 
blended  in  the  middle  line ;  from  their  point  of  union  there  is 
prolonged  downward  in  the  middle  line  of  the  anterior  surface 
of  the  isthmus  a  perpendicular  trunk,  which  is  joined  below 
by  a  varying  number  of  branches  which  issue  from  the  sub- 
stance of  the  lobes  to  form  the  inferior  thyroid  venous  plexus. 
"Figure  i  a,  and  Figures  lO  to  15,  inclusive,  illustrate 
some  of  the  varying  conditions  which  these  branches  present 
as  they  lie  upon  the  anterior  surface  of  the  isthmus.  Of 
great  importance  to  be  borne  in  mind  is  the  occasional  pres- 
ence of  a   large  venous  trunk,  which,  having  its  origin  in  the 


14 


DIPHTHERIA,    CROUP    AND    TRACHEOTOMY, 


FIG.    lO.       INFERIOR    THYROID    VENOUS    PLEXUS.        MEDIAN    TRUNK 
CROSSING  TO  LEFT. 


FIG.    II.       INFERIOR  THYROID  VENOUS  PLEXUS. 

The  trunks  uniting  in  the  lower  part  of  the  space  to  form  a  single  trunk   which  is 
deflected  to  the  right. 


TRACHEOTOMY    IN    CHILDREN. 


IS 


FIG.    12.       INFERIOR  THYROID  VENOUS  PLEXUS. 
Lateral  trunks  only ;  front  of  trachea  clear.     T,  Large  thymus  gland. 


FIG.    13.       INFERIOR  THYROID  VENOUS  PLEXUS. 
Two  lateral  trunks  united  by  oblique  trunk  crossing  in  front  of  trachea. 


i6 


DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 


sub-hyoid  region  above,  passes  down  directly  in  the  median 
line,  deeply  seated,  between  the  third  and  fourth  layers  which 
I  have  described,  covering  the  crico-thyroid  space,  and  receiv- 
ing the  superior  thyroid  veins  at  the  upper  border  of  the  isth- 
mus, taking  the  place  of  the  usual  small  perpendicular  trunk, 


FIG.    14.       INFERIOR  THYROID  VENOUS  PLEXUS. 

Veins  from  left  lobe  crossing  in  front  of  trachea  to  the  right ;  veins  from  right  lobe 
emptying  by  a  short  lateral  trunk  into  right  internal  jugular  vein. 

receiving  the  inferior  thyroid  veins  below,  and  finally  empty- 
ing into  the  great  transverse  vein.  Such  a  large,  deep  anterior 
jugular  trunk  is  seen  in  Fig,  16,  in  which  case  a  large  single 
superficial  median  anterior  jugular  is  seen.  An  identical  con- 
dition, both  of  the  superficial  and  the  deep  vein,  was  met  with 
by  me  in  the  case  of  a  boy,  set.  5  years  (Thomas  .Smith),  in 
whom,  however,  I  succeeded  in  opening  the  trachea  without 
wounding  either.  In  the  subject  which  presented  the  abnor- 
mal course  of  the  superior  thyroid  artery  (Fig.  9),  there  was  also 


TRACHEOTOMY  IN  CHILDREN. 


17 


a  very  large  vein  which  accompanied  the  artery  to  the  middle 
of  the  isthmus,  and  then  turning  directly  downward  ran  in  front 
of  the  trachea  to  disappear  behind  the  sternum.  The  right 
internal  jugular  vein  in  this   subject  was   impervious  from  the 


FIG.    15.       INFERIOR  THYROID  VENOUS  PLEXUS. 
Two  lateral  trunks  connected  by  transverse  branch  in  upper  part  of  space. 

base  of  the  skull  to  within  four  centimetres  from  the  innomi- 
nate, a  fibrous  cord  alone  remaining  in  its  place.  Whenever 
this  deep  median  anterior  jugular  vein  is  present,  any  method 
of  reaching  the  trachea  other  than  that  of  layer  by  layer 
would  inevitably  wound  it  and  occasion  dangerous  haemor- 
rhage. 

"  The  transverse  vessels  of  the  isthmus,  described  above,  are 
enclosed  within  the  fibrous  capsule  of  the  gland,  and  when  the 
fascia  laryngo-thyroidea  is  scratched  through  transversely  at 
the  lower  border  of  the  cricoid  cartilage,  they  are  drawn  down 
with  the  isthmus,  and  thus  are    secure   from   injury  when  this 


1 8  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

method  of  operating  is  adopted.  Incision  of  the  isthmus  it- 
self, it  is  apparent,  may  be  attended  with  a  varying  degree  of 
haemorrhage  and  peril.  Experience  has  shown  that,  though 
in  most  cases  the  bleeding  from  an  incised  isthmus  stops  spon- 
taneously after  the  introduction  of  a  tube,  and  the  restoration 
of  respiration,  yet  repeatedly  has  impending  suffocation  been 
made  complete  by  the  flow  of  blood  into  the  trachea  with  the 
first  inspiration  after  it  had  been  opened  ;  many  cases  also  are 
on  record  in  which  fatal  secondary  hzemorrhage  has  occurred 
from  an  incised  isthmus.  Its  division,  therefore,  is,  when  it  is 
at  all  developed,  always  a  perilous  proceeding,  and  must  pre- 
cipitate a  crisis  at  a  time  when,  especially,  deliberation  and 
caution  are  needed.  In  my  own  experience  I  have  never  been 
compelled  to  cut  it. 

"  The  possible  presence  of  a  large  crico-thyroid  branch,  or 
of  the  superior  thyroid  running  abnormally  across  the  crico- 
thyroid space  is  to  be  borne  in  mind  if  an  incision  is  made  in 
it.  In  Fig.  9,  two  small  arteries  running  across  this  space  are 
seen.  Above  the  thyroid  cartilage,  immediately  below  the 
hyoid  bone,  another  small  transverse  branch  crosses  the  medi- 
an line  of  the  neck,  the  hyoid  branch  of  the  superior  thyroid, 
by  means  of  which  another  anastomosis  between  these  trunks 
is  effected.  I  have  seen  an  incision  through  the  thyro-hyoid 
space  prove  disastrous  by  the  unperceived  escape  of  blood 
into  the  larynx  and  trachea  until  suffocation  was  occasioned. 
The  case  was  that  of  an  infant,  aet.  19  months,  who  had  in- 
haled the  half  of  the  body  of  a  fish's  vertebra  into  its  larynx. 
The  surgeon  attempted  to  extract  it  through  an  incision  which 
he  made  in  the  thyro-hyoid  space  ;  a  sudden  collapse  and  ces- 
sation of  breathing  in  the  little  patient  caused  him  to  abandon 
the  attempt  and  to  hastily  incise  the  trachea  below  and  insert 
a  tube  for  the  purpose  of  re-establishing  the  respiration.  Fur- 
ther attempts  to  remove  the  foreign  body  were  postponed  un- 
til complete  reaction  should  be  obtained.  At  the  end  of  two 
and  a  half  hours  the  child  made  an  attempt  to  cough,  throw- 
ing out  blood,  and  then  suddenly  expired.  Upon  post-mortem 
examination  the   air  passages  were   found  filled  with  blood. 


TRACHEOTOMY  IN  CHILDREN.  I9 

There  having  been  no  external  oozing  at  the  site  of  the  trach- 
eal incision,  which  was  filled  by  the  tube,  the  inference,  almost 
certainty,  was  that  the  haemorrahge  had  come  from  the  sub- 
hyoid wound,  having  increased  in  amount  as  more  perfect  re- 
action had  been  obtained.  The  inferior  pretracheal  space,  the 
space  extending  from  the  lower  margin  of  the  isthmus  of  the 
thyroid  to  the  sternum,  is  much  deeper  than  the  superior  space, 
in  which,  as  has  been  seen,  the  superficial  coverings  are  closely 
applied  to  the  anterior  face  of  the  larynx  and  trachea.  By 
the  recession  of  the  trachea,  which  follows  the  backward  trend 
of  the  lower  cervical  and  upper  dorsal  vertebrae,  a  continually 
increasing  distance  is  produced  between  its  anterior  surface 
and  the  superficial  coverings  which  roof  it  over.  On  either 
side,  this  space  is  walled  in  by  the  sheaths  of  the  great  ves- 
sels of  the  neck,  above  it  is  closed  by  the  blending  of  the  su- 
perficial layers  with  the  envelope  of  the  thyroid  gland,  its 
floor  is  the  anterior  face  of  the  vertebral  column,  and  below  it 
is  continuous  with  the  anterior  mediastinum.  It  is  filled  with 
loose  connective  and  adipose  tissues,  containing  some  small 
lymphatic  glands,  and  affording  a  bed  in  which  ramify  the 
vessels  of  the  region.  The  thymus  gland  may  still  extend  up 
into  it  from  the  mediastinum,  and  occasionally  may  be  of  suf- 
ficient size  to  embarrass  attempts  to  uncover  the  trachea  in 
this  space.  Fig.  12  is  from  a  subject  in  which  the  thymus 
gland  was  found  still  large.  In  the  course  of  an  operation  for 
tracheotomy  in  croup,  as  soon  as  this  space  is  opened  by  the 
tearing  of  the  intermuscular  fascia  and  the  retraction  of  the  mus- 
cles, the  alternate  sinking  in  and  thrusting  up  of  the  loose  tissue 
of  this  space  as  the  labored  efforts  at  inspiration  cause  them  to 
be  sucked  down  behind  the  sternum  and  then  projected  again  up 
into  the  wound  at  each  exspiration,  constituting  a  serious  em- 
barrassment to  deliberate  and  certain  incision  of  the  trachea  ;  a 
special  retractor  to  depress  towards  the  sternum  this  loose  tis- 
sue greatly  facilitates  manoeuvres  in  this  space.  The  vessels 
which  are  normally  present  in  this  space  are  the  branches  of 
the  inferior  thyroid  venous  plexus,  the  origins  of  which  have 
been  described  on  pages  13,  14,  15.    But  the  abnormalities  which 


20 


DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 


occur  here  are  numerous  and  important.  The  number,  ar- 
rangement and  size  of  the  trunks  of  this  plexus  are  subject  to 
great  variations.  The  typical  arrangement  is  the  one  shown  in 
the  frontispiece,  in  Fig.  i  a,  and  again  in  Fig.  6,  in  which  the  radi- 


FIG.    1 6.       THE  PRETRACHEAL  SPACE — FROM  NATURE. 
A,  Superficial  median  anterior  jugular  vein.     B,  Deep  median  anterior  jugular  vein. 

cles  from  the  various  parts  of  the  thyroid  gland  converge  to  a 
common  trunk  which  passes  downward  vertically  in  the  median 
line  in  front  of  the  trachea  and  empties  into  the  great  trans- 
verse innominate  vein  at  its  centre.  Samples  of  the  various 
modifications  of  this  arrangement  which  I  have  found  in  my 
dissections  are  shown  in  Figures  lO  to  l6  inclusive.  Examin- 
ation of  these  illustrations  will  at  once  impress  the  lesson  to 
be  drawn  as  to  the  important  variations  of  this  plexus  with 
reference  to  the  middle  line  of  the  trachea.     Fig.  I2  shows  the 


DIPHTHERIA    IN    CHILDREN.  21 

middle  line  of  the  trachea  not  covered  by  any  vessel,  lateral 
trunks  passing  down  on  either  side.  In  the  subject  (Fig.  7) 
in  which  there  was  no  isthmus,  the  veins  from  the  two  lobes 
converge  as  usual  to  form  a  trunk  in  the  median  line  below. 
The  relations  in  this  space  of  the  large,  deep  anterior  jugular 
trunk,  described  on  pages  16-17,  are  shown  in  Fig.  16. 

"Just  below  the  lower  boundary  of  this  space,  crossing  from 
left  to  right,  is  the  great  transverse  or  left  innominate  vein. 
Normally,  its  upper  margin  is  on  a  level  with  the  sternal  notch, 
its  lower  crossing  the  origins  of  the  arteries,  which  rise  from 
the  arch  of  the  aorta.  Its  possible  elevation  above  the  sternal 
notch,  particularly  when  the  head  is  extended,  should  be  borne 
in  mind.  The  innominate  artery  so  frequently  rises  up  into 
the  lower  part  of  the  pretracheal  space  that  its  presence  there 
can  hardly  be  considerd  an  abnormality.  My  own  dissections 
have  shown  this  to  be  of  greater  relative  frequency  in  young 
children  than  in  adults.  Burns'  observation  was,  that  in  early 
infancy  the  innominate  artery  seldom  turns  to  the  side  of  the 
trachea  lower  than  a  quarter  to  a  half  an  inch  above  the  chest. 


FIG.   17.  FIG.   18. 

Innominate  artery  crossing  trachea  trans-         The  four  great  vessels  arising  separate- 
versely  at  a  high  point.  ly  from  the  arch  of  the  aorta. 

He  has  seen  it  mounting  so  high  in  front  of  the  trachea  as  to 
reach  the  lower  border  of  the  thyroid  gland.  Its  usual  point 
of  origin  from  the  arch  of  the  aorta   is  in  front  of  the  trachea, 


22  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

which  it  crosses  obliquely  so  as  quickly  to  be  found  running  up 
to  its  point  of  bifurcation  along  its  side.  Frequently  its  aortic 
origin  is  to  the  left  of  the  trachea,  as  seen  in  Fig.  i  a, 
and  in  Figures  14  and  15,  and  in  its  upward  course  it  does  not 


FIG.  19. 

The  four  great  vessels  arising  separately 
from  the  arch  of  the  aorta  ;  the  right 
sub-clavian  and  the  left  carotid  cross- 
ing in  front  of  the  trachea  above  the 
sternum. 


FIG.  20. 

The  four  great  vessels  and  the  left  ver- 
tebral arising  separately  from  the  arch 
of  the  aorta ;  right  sub-clavian  from  left 
side  of  arch,  passing  behind  others  in 
front  of  trachea  to  its  proper  side. 


EXPLANATION  OF  REFERENCES  IN  FIGURES  1 8  TO  20. 

a.  Trachea  and  thyroid  glands,  h,  Division  of  the  bronchi,  i,  Arch  of  aorta. 
2,  Descending  aorta.  3,  Right  innominate.  4,  Left  innominate.  (Figures  23  and  24). 
5,  Right  subclavian.  6,  Right  carotid.  7,  Left  subclavian.  8,  Left  primitive  carotid. 
9,  Right  vertebral.     10,  Left  vertebral.     11,  Thyroid  arter)'.     12,  Pulmonaiy  arterj'. 

reach  the  right  of  the  trachea  until  it  has  ascended  above  the 
sternal  notch.  It  may  ascend  vertically  for  some  distance  in 
front  of  or  along  the  left  side  of  the  trachea,  and  then,  turning 
abruptly,  cross  it  transversely,  as  in  the  case  shown  in  Fig.  17. 
The  close  proximity  of  this  trunk  has  been  often  recognized 
by  many  operators  during  the  operation  of  tracheotomy,  being 
seen  or  felt  pulsating  at  the  lower  angle  of  the  wound.  It  has 
repeatedly  been  opened  by  ulceration  from  the  pressure  of  the 
canula  upon  it,  causing  fatal  haemorrhage.  Delay  on  the  part 
of  the  innominate  in  crossing  the  trachea  may  bring  the  right 
carotid  also  in  relation  to  its  anterior   surface.     Burns  records 


TRACHEOTOMY    IN    CHILDREN. 


23 


FIG.  21. 

Carotids  arising  by  a  common  median 
trunk  between  the  origins  of  the  sub- 
clavians. 


FIG.  22. 

Carotids  arising  by  a  common  trunk  on 
right  side,  right  subclavian  from  left 
side  of  arch,  passing  behind  the  others 
in  front  of  the  trachea  to  its  proper  side. 


that,  in  a  boy,  aet.  12  years,  he  found  the  right  carotid  ascend- 
ing in  front  of  the  trachea  for  two  and  a  half  inches  above  the 
top  of  the  sternum  before  it  passed  to  the  side.  Many  varia- 
tions in  the  branches  which  arise  from  the   arch   of  the  aorta 


FIG.  23. 

Right  primitive  carotid  and  subclavian 
arising  separately  from  arch  of  aorta  ; 
innominate  on  left   side. 


FIG.  24. 

Right  subclavian  arising  from  the  arch 
of  the  aorta ;  both  primitive  carotids 
and  the  left  subclavian  by  a  common 
trunk  on  the  left  side. 


24 


DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 


have  been  met  with,  some  of  which  cause  the  front  of  the 
trachea  above  the  sternum  to  be  crossed  by  large  arterial 
trunks.  Figures  i8  to  26,  inclusive,  from  the  work  of  Tillaux, 
"  Anatomic  Topographique,"  in  which  they  are  copied  from 
Tiedemann,  show  some  of  the  most  important  of  these.  Such 
a  graphic  presentation  of  these  will  convey  a  more  perfect  idea 
of  the  anomalies  than  any  description. 

"A  middle  thyroid  artery,  arteria  thyroidea  ima,  ascending 
vertically  in  front  of  the  trachea  up  to  the  thyroid  gland,  is 
found,  according  to  Neubauer,  in  one  out  of  every  ten  cases. 
It  is  derived  from  the  arch  of  the  aorta,  or  the  innominate 
usually.  Irregular  origins  from  other  of  the  great  vessels  at 
the  root  of  the  neck  have  been  noted.  Fig.  27  shows  two  such 
vessels  of  small  size,  from  one  of  my  own  injections.  Fig.  28, 
from  Tiedemann,  shows  a  large  median  trunk  arising  from  the 


FIG.  25. 

Left  primitive  carotid  arising  from  right 
innominate. 


FIG.  26. 

Left  primitive  carotid  arising  from  right 
innominate,  left  vertebral  from  arch  of 
the  aorta. 


aorta  which  took  the  place  of  the  usual  inferior  thyroid  ar- 
teries. Blandin  states  that  he  has  seen  a  middle  thyroid  ves- 
sel as  large  as  the  radial  artery.  Burns  records  four  cases  in 
which  the  innominate  artery,  when  on  a  level  with  the  sternum, 
just  before  bifurcating,  gave  off  from  its  left  side  a  branch 
about  the  size    of  a   crow-quill,  which   soon   divided   into   two 


TRACHEOTOMY  IN  CHILDREN.  2$ 

main  branches,  and  then  broke  up  into  a  number  of  twigs 
which  ascended  along  the  front  of  the  trachea  to  the  thyroid 
gland  in  such  a  manner  that  there  was  hardly  a  single  point  of 
the  trachea  into  which  an  incision  could  be  made  without  di- 
viding some  of  the  pretty  large  twigs  of  the  vessel.  The  in- 
ferior thyroid  arteries  occasionally  take  an  abnormal  course, 
in  which  one  of  them  crosses  in  front  of  the  trachea.  Norm- 
ally these  arteries  having  passed  up  on  either  side  from  the 
subclavian,  behind  the  sheath  of  the  great  vessels,  to  a  point 
opposite  the  first  ring  of  the  trachea,  pass  horizontally  inwards, 
then  downwards,  then  upwards  again,  having  made  thus  two 
curves  in  opposite  directions,  and  finally  penetrate  the  gland 
from  behind.  One  of  the  inferior  thyroid  trunks  is  sometimes 
wanting,  in  which   case   its  place  is  supplied  by  a  branch   from 


FIG.  27.  FIG.  28. 

Arterias  thyroidea;  imie,  double.  Arteria  thyrodea  ima,  single  large  aortic 

branch  replacing  the  lateral  inferior 
thyroids. 

the  other  side,  which  crosses  to  its  destination  in  front  of  the 
trachea.  Burns  describes  a  preparation  in  the  possession  of 
Dr.  Barclay,  in  which  the  two  inferior  arteries  arise  by  a  com- 
mon trunk  from  the  right  subclavian  artery,  the  vessel,  passing 
to  the  front  of  the  trachea ;  the  left  also  ascends  till  within 
two  tracheal  rings  of  the   cricoid  cartilage.     The   replacement 


26  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

of  both  inferior  thyroids  by  a  common  median  trunk  from  the 
aorta  (Fig.  28)  has  already  been  noticed. 

From  this  presentation  of  the  varying  vascular  conditions  in 
the  pretracheal  space,  it  is  evident  that  the  greatest  caution 
should  be  used  in  attempting  to  approach  the  trachea  through 
it.  There  is  no  line  of  safety  to  be  preserved.  Whatever 
freedom  from  other  complications  may  be  present,  the  presence, 
at  least,  of  an  important  venous  plexus,  covering  the  trachea 
in  the  middle  line,  will  demand  special  precautions  for  its  avoid- 
ance, except  in  occasional  instances.  In  addition  to  the  dan- 
gers and  difficulties  which  the  haemorrhage  from  the  wound  of 
this  plexus  occasions,  the  additional  peril  of  entrance  of  air 
into  the  heart  through  them  has  been  found  to  be  no  chimera. 
The  case  which  occurred  in  the  experience  of  Professor  H.  B. 
Sands,  in  1868,  in  which,  while  performing  tracheotomy  upon 
an  adult,  immediate  death  resulted  from  the  rushing  in  of  air 
through  an  incision  in  an  inferior  thyroid  vein  which  had  been 
prevented  from  collapsing  by  the  fact  that  the  tissues  in  which 
it  was  imbedded  were  indurated  by  recent  inflammatory^  exu- 
dates— this  case  cannot  be  considered  as  germane  to  the  con- 
sideration of  the  dangers  to  be  apprehended  from  operations 
in  which  the  tissues  of  the  pretracheal  space  are  healthy.  But 
the  case  reported  recently  by  Professor  Parise,  of  Lille,  France, 
in  the  "Archives  Generales  de  Medecine,"  1880,  p.  571,  illus- 
trates perfectly  this  danger.  While  doing  tracheotomy  for 
diphtheretic  croup  in  a  girl,  set.  5  years,  after  having  made  the 
usual  incisions,  wishing  to  uncover  more  fully  the  trachea, 
which  was  covered  by  an  unusually  large  thyroid  isthmus,  this 
surgeon  wounded  the  left  branch  of  the  middle  thyroid  vein 
near  its  junction  with  that  from  the  right  side ;  copious  haem- 
orrhage resulted.  In  the  effort  to  seize  the  trunk  of  the  vein 
to  tie  it,  the  superficial  wall  only  was  seized  and  raised  up, 
which  rendered  the  vein  patent  for  the  moment,  during  which 
a  strong  inspiration  took  place,  a  sharp  hiss  was  heard,  and  in- 
stant death  followed  without  a  cry  or  struggle.  Upon  autopsy, 
air  was  found  in  the  right  cavity  of  the  heart. 

"  The  looseness  of  the  peritracheal  connective  tissue  permits 


TRACHEOTOMY  IN  CHILDREN.  2/ 

the  trachea  to  be  Hfted  up  from  its  bed  and  brought  near  to  the 
surface  when  once  it  has  been  exposed.  If  a  pair  of  catch- 
forceps,  hke  the  pinces  hcemostatigttes  of  Pean,  be  fastened  on 
either  side  into  the  layer  of  fascia  that  has  been  torn  aside  from 
the  front  of  the  trachea,  and  then  be  permitted  to  fall  outward 
to  the  side  of  the  neck,  by  their  own  weight  they  will  lift  up 
the  trachea,  and  depress  the  side  walls  of  the  pretracheal  space 
so  that  the  trachea  is  rendered  quite  superficial,  and  its  incis- 
ion, and  exploration  greatly  facilitated. 

"  Some  points  as  to  the  laryngo-tracheal  tube  itself  remains 
for  consideration.  In  the  child,  the  thyroid  cartilage  is,  rela- 
tively, little  developed,  and  its  upper  border  rises  up  behind 
the  body  of  the  hyoid  bone,  which  obscures  it  except  when 
the  head  is  extended.  This  is  well  shown  in  Fig.  7,  which  is 
a  life-size  representation  of  the  parts  taken  from  a  girl,  set.  6 
years.  The  outlines  of  the  thyroid  cartilage  can  not  be  clearly 
made  out  through  the  overlying  tissues.  The  resistant  outline 
of  the  cricoid  cartilage,  however,  can  always  be  recognized 
through  the  skin  in  children  [?],  a  point  of  which  Cassaignac 
made  much  in  his  method  of  tracheotomy.  The  distance  be- 
tween the  hyoid  bone  and  the  cricoid  cartilage,  in  a  child  three 
or  four  years  of  age,  is  about  i  centimetre ;  in  the  six-year  old 
specimen,  Fig.  7,  the  distance  is  i\/.,  centimetres.  This  space 
may  be  more  than  doubled  by  bending  the  head  strongly  back- 
ward. The  relatively  small  size  of  the  larynx  in  children  per- 
sists until  the  time  of  puberty,  so  that  the  differences  in  size 
between  the  larynx  of  a  child  of  three  years  and  of  twelve  are 
small,  and  can  not  be  estimated  by  the  differences  in  stature. 
The  result  of  this  is  that  the  cricoid  cartilage  is  always  placed 
relatively  high  in  the  neck  of  a  child,  and,  as  its  position  de- 
termines the  position  of  the  isthmus  of  the  thyroid,  the  space 
between  the  lower  border  of  the  gland  and  the  sternum  is  rel- 
atively large.  As  the  larynx,  however,  begins  to  evolve  at 
puberty,  the  cricoid  cartilage  is  depressed,  the  thyroid  gland 
descends  along  with  it,  and  the  comparative  distance  between 
the  gland  and  the  sternum  is  lessened  in  the  adult.  These 
points  are  especially  noted  by  Burns  in  his  work  on  "  The  Sur- 


28  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

gical  Anatomy  of  the  Neck,"  who  drew  from  them  inferences 
in  favor  of  incising  the  trachea  in  children  below  the  isthmus. 
Tillaux  gives  a  table  of  distances  between  the  cricoid  cartilage 
and  the  sternum  in  thirty-one  children  between  the  ages  of  two 
and  a  half  and  ten  years.  The  average  for  those  between  two 
and  three  years  is  3\/2  centimetres ;  for  those  between  three 
and  six  years,  4  centimetres ;  for  those  between  six  and  ten 
years,  about  5  centimetres ;  while  the  average  distance  in 
twenty-four  adults  was  but  672  centimetres,  the  lowest  being 
4^.,,  and  the  greatest  8^/,.  I  have  myself  often  felt  surprised 
to  find  in  very  young  children  upon  whom  I  have  had  occasion 
to  operate,  quite  as  much  room  in  the  pretracheal  space  as  in 
children  much  older.  As  far  as  the  trachea  itself  is  concerned, 
an  incision  below  the  isthmus  is  certainly  favored,  for  the 
younger  the  subject  the  less  room  there  is  above  the  thyroid 
isthmus  and  the  more  below  it  for  gaining  access  to  the  air- 
tube.  The  greater  depth  and  the  varying  vascular  networks 
that  are  found  in  front  of  it  in  the  pretracheal  space,  however, 
increase  materially  the  dangers  of  attempts  to  reach  it  here.  If, 
however,  these  difficulties  can  be  met  by  skillful  and  deliber- 
ate [!]  manipulation,  the  question  of  what  particular  point 
should  be  chosen  for  the  incision  ought  to  be  decided  less  on 
the  score  of  operative  difficulties  than  on  that  of  therapeutic 
value.  Whichever  will  best  secure  the  good  aimed  at  by  the 
operation  ought  to  be  chosen.  In  my  own  experience,  I  find 
that  my  earliest  operations  were  through  the  cricoid  and  the 
first  ring ;  then  followed  a  series  in  which,  by  depressing  the 
isthmus,  I  incised  the  upper  tracheal  rings.  In  my  last  fifteen 
operations  I  have  performed  the  low  operation.  My  experi- 
ence has  been  sufficient  to  assure  me  that,  as  a  rule,  the  ana- 
tomical difficulties  which  the  low  operation  involve  may  be  so 
controlled  as  to  make  it  safe  and  facile,  while  if,  on  exposure 
of  the  contents  of  the  pretracheal  space,  it  is  apparent  that 
great  peril  would  be  incurred  by  persevering  in  the  attempt  to 
reach  the  trachea  through  it,  prolongation  of  the  incision  up- 
wards so  as  to  expose  the  space  above  the  isthmus  is  always 
possible.     *     *     * 


TRACHEOTOMY  IN  CHILDREN.  29 

"  If  laryngo-tracheotomy,  or  tracheotomy  through  the  upper 
rings  by  depressing  the  isthmus  is  chosen,  the  cricoid  prom- 
inence should  fall  midway  in  the  incisions ;  if  the  low  opera- 
tion is  to  be  done,  the  incision,  beginning  above  the  cricoid, 
should  extend  downward  from  it  to  the  sternum. 

"The  elastic  and  compressible  nature  of  the  tracheal  rings 
in  young  children  may  be  the  occasion  of  a  serious  complica- 
tion, embarrassing  the  last  steps  of  an  operation  for  tracheot- 
omy. In  conditions  of  laryngeal  stenosis  the  force  of  the  at- 
mospheric pressure  upon  the  parts  at  the  outlet  of  the  thorax 
is  extreme,  and  is  supported  by  the  musculo-aponcurotic  cov- 
ering which  is  stretched  over  the  trachea  from  cricoid  to  stern- 
um, secured,  as  it  is,  along  the  sides  to  the  sterno-cleido-mas- 
toid  muscles.  After  this  protective  covering  has  been  incised, 
the  tissues  beneath  are  exposed  to  the  force  of  the  atmos- 
pheric pressure.  The  sucking  downward  behind  the  sternum 
of  the  loose  pretracheal  connective  tissue  has  already  been 
noted ;  the  trachea  is  affected  by  the  same  pressure,  and  in 
children,  in  whom  the  walls  of  the  tube  are  much  less  resist- 
ant than  in  adults,  it  may  be  so  flattened  by  the  retraction  or 
insucking  of  its  anterior  wall  that  the  already  scanty  supply  of 
air  to  the  lungs  is  materially  diminished  and  the  symptoms  of 
impending  asphyxia  become  alarmingly  aggravated.  The  more 
intense  the  obstructive  symptoms  previous  to  the  operation,  the 
greater  the  liability  to  peril  from  this  cause,  and  the  more 
likely  to  occur  a  crisis  in  which  instantaneous  opening  of  the 
trachea  at  any  hazard  is  demanded. 

"  The  mucous  membrane  of  the  trachea  receives  from  the 
inferior  thyroid  arteries  vessels  which  may  acquire  in  the  adult 
some  development  and,  even  in  children,  afford  a  vascular  sup- 
ply to  this  membrane  that  requires  notice  in  a  surgical  point  of 
view,  in  consequence  of  the  haemorrhage  which  they  occasion, 
in  tracheotomy,  when  the  trachea  is  incised.  However  per- 
fectly bleeding  may  have  been  arrested  before  the  trachea  is 
opened,  some  haemorrhage  will  follow  the  opening  of  the 
trachea,  the  blood  flowing  into  the  tube  and  occasioning  the 
violent  spasm  of  coughing  which   occurs   when  the    trachea  is 


30 


DIPHTHERIA,    CROUP    AND    TRACAEOTOMY. 


Opened.  The  impression  has  been  usual  that  this  paroxysm  of 
cough  is  caused  by  the  stimulating  effect  of  the  sudden  free 
access  of  the  air  to  the  interior  of  the  trachea.  The  idea  that 
it  is,  in  fact,  caused  by  the  entrance  of  blood  into  the  tube  is 
advanced  by  Tillaux,  who  supports  it  by  an  observation,  com- 
municated to  the  Surgical  Society  of  Paris,  in  1874,  of  a  case 
in  which,  having  opened  the  trachea  in  an  adult  by  the  use  of 
the  thermo-cautery,  there  was  not  a  drop  of  blood  shed  ;  when 


FIG.  29. 

Aperture  of  glottis  when  fully  dilated. 
Actual  size  from  nature  in  child  2 
years  and  8  months. — Holmes. 


FIG.   30. 

Transverse  section  through  cricoid  car- 
tilage. Same  subject  as  Fig.  29. 
Natural  size. 


FIG.   31.  FIG.  32. 

Same  parts  in  child  of  3  years  and  10  months. ' 

the  trachea  was  opened  no  cough  followed,  and  those  present, 
not  hearing  the  characteristic  sound,  could  not  believe  the  op- 
eration finished.  Burns  quotes  a  case  in  point  from  Sabatier, 
in  which  a  soldier,  having  suffered  tracheotomy  for  the  relief 
of  suffocative  laryngitis,  was  so  tormented  by  a  convulsive 
cough  produced  by  blood  falling  into  the  trachea  that  it  was 
impossible  to  keep  the  canula  in  place.  Relief  was  finally  ob- 
tained by  turning  him  upon  his  face  until  the  blood  ceased  to 
flow.     The  patient   ultimately  recovered.     Haemorrhage  from 


TRACHEOTOMY  IN  CHILDREN. 


31 


this  source  is  usually  insignificant  in  its  amount,  and  is  speedily 
arrested  by  the  pressure  of  the  canula  when  inserted.  The  di- 
ameter of  the  interior  of  the  tube  is  of  importance  to  be  considered 
with  reference  to  the  size  of  the  canula  to  be  used  after  trach- 
eotomy. The  diameter  of  the  orifice  of  the  glottis  is  always 
much  less  than  that  of  the  trachea  proper.  The  relative  di- 
mensions of  the  entrance  to  the  air  tube,  and  of  the  tube  it- 
self, are  well  shown  in  Figures  29  to  34,  copied  from  Holmes 
on  "The  Surgical  Diseases  of  Children."  The  inference  has 
been  drawn  from  this  that  the  tube  to  be  used  after  tracheoto- 
my need  not  be  of  the  full  size  that  the  calibre  of  the  trachea 


FIG.   33.  FIG.   34. 

Same  parts  in  child  of  9  years  and  9  months. 


would  admit.  The  special  conditions  which  children  present 
after  tracheotomy  for  croup,  by  the  continual  accumulation  in 
the  tube  of  tenacious  mucus,  make  it  desirable,  however,  that 
in  such  cases  tubes  of  as  large  calibre  as  possible  should  be 
used.  Tillaux  gives  measurements  of  the  diameter  of  the 
trachea  in  nine  children  between  two  and  five  years,  and  Marsh, 
in  the  "  St.  Bartholomew's  Hospital  Report,"  Vol.  HI.,  1867, 
of  eighteen  children,  of  the  same  age.  From  these  measure- 
ments it  appears  that,  while  there  is  a  gradually  increasing  aver- 
age diameter,  there  are  many  individual  variations  in  those  of 
the  same  age,  and  a  diameter  in  the  older  ones  smaller  than 
in  some  of  the  younger  ones  is  not  uncommon." 


"Boy, 

1 6  months, 

<( 

27. 

years, 

<i 

3 

n 

4'/. 

Girl, 

5 

it 

5'/. 

(( 

6 

(< 

7 

<( 

8 

Boy. 

9 

Girl, 

13 

32  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

[Table  of  the  distances  which  separate  the  posterior  wall  of 
the  trachea  from  the  anterior  wall,  at  a  level  with  the  fourth 
ring. — Boiirdillat : 

Distance — Millimetres. 

-  7 
8 
9 

10 

-  9''. 
10 

I0'/2 
II 

12 

-  I2V, 

-  I3VV' 

The  diameter  of  the  trachea  varies  according  to  age,  as  well 
as  with  the  subject,  as  follows: 
Age — Years.  Variation — mm.  in. 

17,—  4  -  -  -  between  6—  8=7,-73 

2     —  4  -  -  -  "         8—10=73—75 

4     — 10  -  -  -  from     10 — 12=75 — V2 

10    — 20  -  _  -  "      12 — 19=72 — 7^ 

As  a  rule,  all  ages  up  to  3  years  can  wear  a  tube  one-fourth 
an  inch  in  outside  diameter — 6  mm.  (^/^  in.);   of  course   over 
2  years,  a  little  larger. 

From  3  to    5  years,  -  -  8  mm.      (73  in.) 

"      5  to  10        "  -  -  10     "         (78  in.) 

"     10  to  20        "  -  -  12     "     (75  to  72  in.) 

Dr.  Pilcher  has  used  the  same  size — 772  mm.,  outside  diam- 
eter— in  all  his  cases  (31  cases  in  1881),  from  13  months  to  10 
years  old]. 


DIPHTHERIA. 


DEFINITION.— HISTORY. 

Diphtheria  is  a  specific,  infectious,  general  disease,  trans- 
missible by  inhalation,  by  contact  and  probably  by  inocula- 
tion, the  principle  characteristic  of  which  is  the  production 
upon  the  mucous  membranes,  or  upon  the  deep  layer  of  the 
epidermis,  of  fibrinous  exudations  commonly  called  false  mem- 
branes. 

Known  from  the  most  remote  antiquity  but  differently  un- 
derstood by  numerous  authors  who  have  observed  it,  it  has  re- 
ceived in  the  course  of  the  ages  names  which  recall  either  one 
of  its  principal  symptoms,  or  the  idea  which  has  been  formed 
of  its  nature,  or  the  country  in  which  it  has  prevailed.  Hence, 
the  names  ulcus  Syriacuni,  ulcus  Egyptiacimi,  garrotillo,  morbus 
suffocajis,  morbus  or  affectus  strangulatorius,  pestilentis  gutturis 
affectio,peda7tcho  maligna,  angina  maligna,  anginosa  passio,  mal 
de  gorge  gangreneux,  ulcere  gangreneux,  angina  polyposa,  croup, 
angi?ie  maligne,  up  to  the  time  when  Bretonneau  gave  it  that  of 
diphtherite,  then  diphtheria,  derived  from  the  greek  word  litfOipa 
membrane. 

Diphtheria,  a  disease  unique  and  specific,  will  be  described 
in  accordance  with  the  method  ordinarily  applied  to  well- 
defined  pathological  types.  The  treatise  will  form  several 
chapters  in  which  will  be  reviewed  the  history  from  the  most 
remote  periods,  the  pathological  anatomy,  symptoms,  diagno- 
sis, etiology,  nature  of  the  disease,  prognosis  and  treatment. 

By  pursuing  the  annals  of  science  one  may  assure  himself 
that  diphtheria  is  not  a  new  disease  and  that  the  different  forms 
observed  in  our  day  existed  already  in  antiquity. 

The  Jews  fasted,  it  is  said,  the  fourth  day  of  the  week  for 
the  sake  of  children  succumbing  suddenly  under  an  attack  of 

(33) 


34  niPHTAERIA,    CROUP    AND    TRACHEOTOMY. 

angina.  It  is  believed  that  the  proof  is  found  in  the  works  of 
Hippocrates,  that  diphtheria  was  not  unknown  at  that  period. 
But  by  examining  the  quotations  produced  in  its  support  one 
cannot  refrain  from  entertaining  doubts  as  to  the  interpretation 
which  has  been  given  them.  The  words  angina  and  cynanchc 
did  not  signify  among  the  ancients  a  disease  Hmited  to  the 
throat  or  to  the  upper  portions  of  the  air  passages  ;  they  meant 
all  those  which  occasioned  dyspnoea;  to-wit:  Diseases  of  the 
lungs,  phthisis,  etc.  "  However,"  says  Liltre,  "it  is  not  un- 
reasonable to  imagine  a  membranous  inflammation,  seeing  that 
the  Hippocratic  writings  attribute  to  certain  anginas  a  very  pe- 
culiar expectoration." 

About  a  hundred  years  before  our  era,  Asclepiades  of  Bith- 
ynia,  the  writings  of  whom,  though  lost,  are  known  by  the 
quotations  taken  from  them  by  Aretaeus,  Coelius  Aurelianus, 
and  Galen,  seems  to  have  known  diphtheria,  because  he  prac- 
ticed, according  to  these  authors,  laryngotomy.  Had  this 
operation  been  tried  previously?  There  is  doubt  on  this  sub- 
ject, for  Ccelius  Aurelianus  says  in  one  place  in  speaking  of 
Asclepiades:  "  Dehinc  a  veteribus probatam,  approbat  arteriae 
divisuram,  ad  respirationem  faciendam,  quam  laryngotomiam 
vocant."  And  again,  "  Est  etiam  fabulosa  arteriae  ad  respira- 
tionem divisura  et  quae  a  nu/lo  sit  antiquoruvi  tradita,  sed  cadu- 
ca  atque  temeraria  Asclepiadis  invcntionc  afifirmata."  At  best, 
CceHus  formed  an  indifferent  idea  of  tracheotomy  ;  he  also  em- 
phasized his  reprobation :  "  Ne  tantum  scelus  angusta  ora- 
tione  damnemus,  lebris  quos  de  adjutoriis  sumus  scripturi,  re- 
spondebimus."  The  first  description  of  agina  gangrenosa  is 
given  by  Aretaeus,  of  Cappadocia,  who  lived  in  the  time  of 
Vespasian.  We  find  there  indicated  the  varieties  of  diphther- 
itic angina  discrete  and  benign,  as  well  as  the  gangrenous  and 
malignant  forms.  The  author  signalized  also  the  extension  to 
the  respiratory  passages  and  death  by  suffocation.  This  de- 
scpiption,  given  by  a  master's  hand,  deserves  to  be  reproduced  : 
"  Ulcers  appear  upon  the  tonsils,  some  are  benign  others  pes- 
tilential and  fatal ;  the  pestilential  ones  are  broad,  deep,  and 
tumefied,  covered  over  with  a  white,  livid  or  black  concrete 


DIPHTHERIA.  35 

product.  But  if  this  concretion  gains  in  depth  it  becomes  what 
is  called  in  Greek  an  eschar,  or  in  Latin  a  crust.  A  vivid  in- 
flammatory redness  surrounds  this  crust;  discrete,  small  pus- 
tules arise  around,  then  others  supervene,  and  uniting  with  the 
former  ones  form  a  large  broad  ulceration.  By  continuing  its 
destructive  action  this  may  extend  into  the  mouth  and  reach 
the  uvula;  it  also  invades  the  tongue  and  the  gums,  by  which 
the  teeth  become  loosened  and  blackened.  *  *  *  "Phg  [^_ 
flammation  extends  also  to  the  neck.  *  *  *  Yj^g  patients 
die  at  the  end  of  a  few  days.  *  *  *  And,  if  the  malady 
invades  the  chest  by  the  trachea,  it  causes  suffocation  on  the 
same  day.  Children  up  to  the  age  of  puberty  are  the  most 
exposed  to  this  disease."  It  is  necessary  to  read  afterwards 
the  startling  description  of  croupal  angina  :  "  A  cough  occurs 
with  the  dyspnoea  and  death  is  produced  under  the  most  pitia- 
ble conditions.  The  pale  or  livid  countenance  expresses  suf- 
fering whenever  the  tonsils  are  compressed.  When  the  pa- 
tient lies  down  he  immediately  arises,  not  being  able  to  toler- 
ate the  horizontal  position  ;  if  he  sits  up  the  fatigue  soon  com- 
pells  him  to  lie  down  again,  and  most  of  the  time  he  walks 
restlessly  to  and  fro,  the  prey  of  violent  agitation.  Inspirations 
are  long,  the  expirations  short,  the  voice  is  hoarse,  then  be- 
comes extinct.  These  symptoms  grow  rapidly  worse  until  the 
exhausted  patient  succumbs."  Everything  tends  to  the  be- 
lief that  the  physician  of  Cappadocia  considered  angina  mal- 
igna and  croup  as  two  phases  of  one  and  the  same  disease. 
He  mentions  also  that  these  anginas  raged  principally  in 
Egypt  and  in  Syria,  whence  the  name  u/cus  Syriacuui  or  Egyp- 
tiacum.  Tournefort,  traveling  in  these  countries  in  the  eight- 
eenth century,  found  the  same  disease,  which  he  designated  as 
charbon  du  fond  de  la  gorge.  Galen,  who  wrote  in  the  second 
century,  made  mention  of  the  pseudo-membranous  expectora- 
tion :  "  A  fragment  of  expelled  membranous  tunic  denotes  the 
existence  of  an  ulceration,  but  in  what  part  is  it  found  ?  This 
is  what  will  teach  us  the  seat  of  the  disease.  *  *  *  If  it 
is  produced  by  coughing,  it  is  an  affection  of  the  larynx,  of 
the  trachea,  or  of  the  lungs ;  if  it  is  expelled  by  spitting 
(hawking)  it  is  an  affection  of  the  pharynx." 


36  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

Coelius  Aurelianus,  after  Galen,  gives  the  description  of 
grave  anginas  and  describes  certain  symptoms  which  corre- 
spond to  croup  and  to  diphtheritic  paralysis.  He  speaks  of 
disturbance  of  phonation,  defective  articulation,  extinction  of 
the  voice,  and  of  its  sounding  like  the  barking  of  a  dog,  of 
the  laryngo-tracheal  wheezing,  the  lividity  of  the  face,  the  re- 
jection of  drinks  through  the  nose,  etc.  He  mentions  the 
practice  of  Asclepiades,  consisting  of  scarifications  of  the  ton- 
sil and  even  of  performing  laryngotomy.  After  Coelius  Aure- 
lianus, silence  existed  for  a  long  series  of  ages,  and  was  only 
broken  by  ^tius,  of  Amida,  in  the  fifth  century,  who,  com- 
menting on  Aretaeus,  added  to  the  description  of  his  predeces- 
sor the  results  of  his  own  experience  :  "  The  crusty  and  pesti- 
lential ulcers  of  the  tonsils  are  usually  not  preceded  by  any 
discharge.  They  are  principally  observed  in  children  ;  *  * 
they  are  at  one  time  white-like  spots ;  at  another  of  an  ashy 
or  rusty  color  j  *  *  *  putrefaction  follows  then,  *  *  * 
there  are  patients  in  which  the  throat  becomes  corroded  when 
the  ulcerations  have  persisted  for  a  long  time  and  gained  in 
depth ;  their  voice  becomes  hoarse,  and  they  are  in  danger  up 
to  the  seventh  day."  The  author  continues  by  blaming  those 
who  apply  energetic  remedies  to  the  disease  and  tear  away  the 
patches.  This,  he  says,  should  not  be  done  before  they  are 
about  to  separate.  His  practice,  we  shall  see  further  on,  ap- 
proaches very  closely  to  that  which  I  shall  defend.  Paulus 
^gineta  has  the  reputation  of  having  spoken  of  diphtheria. 
It  is  not  true.  To  make  amends,  he  transmits  to  us  the  opera- 
tive procedure  by  Antyllus  for  tracheotomy.  Here  ends  the 
testimony  from  antiquity.  The  chain  is  broken,  the  tradition  is 
lost ;  we  must  traverse  all  the  middle  ages  and  come  to  the 
middle  of  the  sixteenth  century  to  find  new  documents. 
At  this  period  fatal  epidemics  passed  over  Europe  and  found 
numerous  historians.  These  authors  confound  diphtheria  with 
gangrene ;  everything  is  ascribed  to  this  latter.  The  first  is 
Peter  Forest,  who  observed  in  1557  an  epidemic  of  angina  at 
Alkmaer  in  Holland ;  he  was  attacked  with  it  himself.  He 
pointed  out  propagation  into  the  air-passages  and  suffocation. 


DIPHTHERIA.  37 

In  1563  another  epidemic  extended  over  the  kingdom  of 
Naples  and  Sicily;  in  1564  it  reached  Constantinople  and  Al- 
exandria. Its  historian  is  Anthony  Soglia,  of  Naples,  quoted 
by  the  elder  Chomel.  In  1565  an  epidemic  of  the  same  na- 
ture was  reported  by  John  Weirus,  who  informs  us  that  Dant- 
zig,  Cologne  and  Augsburg  were  infected  by  it  at  the  same 
period.  He  gave  to  the  disease  the  name  of  angina  pestilen- 
tia.  In  1576  Baillou  gave  the  description  of  an  epidemic 
which  prevailed  in  Paris.  For  the  first  time  since  ^Etius  he 
describes  the  false  membrane,  which  was  in  reality  observed 
not  by  himself  but  by  a  surgeon  whose  name  he  does  not 
give :  "A  surgeon  declared  he  opened  the  body  of  a  patient 
who  had  died  of  dyspnoea  in  connection  with  an  unknown  dis- 
ease. He  found  a  thick,  resistant  humour  stretched  like  a 
membrane  over  the  orifice  of  the  trachea  in  such  a  manner 
that  the  external  air  could  neither  enter  nor  escape  freely,  and 
that  it  had  caused  sudden  suffocation."  In  1583-87-91-96, 
and  from  1600  to  1605,  then  in  161 3  epidemics  showed  them- 
selves in  Spain.  The  disease  was  designated  by  the  name 
ano  del  garrotillo,  derived  from  the  instrument  called  garrot 
which  was  used  to  execute  criminals  by  strangling.  Some  in- 
teresting accounts  are  due  to  Mercado,  physician  of  Philip 
III,  (1608);  he  reported  among  others  the  fact  of  a  child  who 
communicated  the  disease  to  his  father  by  biting  the  finger  of 
the  latter  while  he  was  removing  from  its  throat  a  piece  of 
false  membrane;  and  to  Francis  Perez  Cascalez  (1611),  who 
recognized  the  false  membranes  and  employed  for  them  gargles 
of  alum  and  sulphate  of  copper.  Christobal  Perez  Herrera 
describes  diphtheria  and  notes  its  production  upon  the  skin 
and  upon  wounds ;  he  observed  in  autopsies  the  presence  of 
false  membranes,  and  made  them  the  anatomical  characteristic 
of  the  disease.  Miguel  Heredia  distinguished  two  forms,  one 
suffocative  and  the  other  asthenic ;  he  observed  paralysis  of 
the  velum  palati,  the  pharynx  and  the  limbs ;  he  believed  in  a 
secondary  infection  by  resorption  of  the  products  and  recom- 
mended the  use  of  caustics  from  the  first  with  the  view  of  pre- 
venting it.     He  mentions    also  the  pseudo-membranous  pro- 


38  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

ductions  which  cause  the  death  of  children  because  they  could 
neither  cough  nor  spit  out  the  products.  Antonio  Maria  Bar- 
bosa,  in  his  remarkable  memoir  on  croup  again  cites  the  works 
— too  little  known — of  several  Spanish  and  Portugese  physi- 
cians, among  whom  should  be  mentioned  Juan  de  Villareal, 
Juan  Alonzo  de  Fontecha,  Ildefonso  Nunez,  Thomas  de  Agu- 
jar,  Andre  Tamajo,  Alonzo  Nunez  de  Pereira,  Ildefonso  Mene- 
zes,  Juan  de  Soto,  Francisco  de  Figueiras  who  wrote  at  Lima, 
in  1616,  Lorenzo  de  San  Millan  and  Geronimo  Gil  del  Pina.  Bar- 
bosa  has  found  some  documents  of  the  sanitary  police  which 
attest  the  existence  of  an  epidemic  of  diphtheria  in  Portugal 
(1626).  In  them  is  found  an  account  of  corroding  and  malig- 
nant ulcers  of  the  throat  which  destroyed  children  in  large 
numbers  while  adults  recovered.  In  1668  Thomas  Rodrigues 
de  Viga,  professor  at  the  University  of  Co'imbra,  proposed 
tracheotomy ;  he  is  imitated  by  Francisco  da  Fonseca  Hen- 
riques.  Another  Portuguese  physician,  Manoel  Joaquin  Hen- 
riques,  speaks  of  an  epidemic  which  took  place  in  1755-  Soa- 
rez  Barbosa  gave,  in  1789,  the  account  of  an  epidemic  which 
raged  at  Leiria,  in  Portugal.  This  able  and  conscientious  ob- 
server, who  was  himself  attacked,  describes  the  white  false 
membranes.  Blood-letting,  which  he  employed  at  first,  was 
abandoned  by  him ;  he  had  recourse  to  emetics  with  advant- 
age, giving  the  preference  to  ipecacuanha  over  tartar    emetic. 

Having  been  led  forward  by  the  important  works  of  the 
Spanish  physicians  too  far  in  advance,  I  now  return  to  the 
Seventeenth  century.  From  Spain  diphtheria  passed  into  Italy. 
It  was  found  at  Naples  in  161 8.  It  called  forth  the  descrip- 
tions of  Sgambati  (1619),  Carnevale  (1620),  Francis  Nola  (1620), 
Foglia  (1620),  Broncoli  (1622),  Alaymo  (1625),  at  Palermo; 
Cortesio  (1625),  Prosimi  (1635),  at  Messina;  Signini  (1636),  at 
Rome ;  Zacutus  Lusitanus  and  Marcus  Aurelius  Severinus  at 
Naples  (1641).  We  should  place  by  the  side  of  these  authors, 
Rene  Moreau,  in  France,  and  Thomas  Bartholin,  who  com- 
mented on  Severinus. 

The  disease  which  they  describe  under  the  name  of  morbus 
strangulatorius,  and  angina  pestilentia,  is  in  nearly  all   respects 


DIPHTHERIA.  39 

like  that  of  the  Spanish  physicians.  It  appeared  first  at  Na- 
ples around  the  Chiaja,  then  it  extended  to  the  other  quarters 
and  to  the  provinces.  It  commenced  by  slight  inflammation  of 
the  throat ;  very  soon  the  affected  parts  became  white ;  the 
breath  assumed  a  fetid  odor,  deglutition  became  impossible,  the 
voice  became  extinct,  respiration  was  embarrassed  and  the 
children  succumbed  as  if  they  had  been  strangled  with  a  cord. 
Its  tendency  to  generalization,  and  its  contagious  properties, 
without  distinction  of  age  or  sex,  are  noted  by  all  authors.  It 
attacks  especially,  says  Cortesio,  persons  who  attend  the  pa- 
tients. Sgambati  speaks  of  diphtheritic  coryza.  Severinus 
witnessed  certain  cases  of  adynamia,  and  a  kind  of  imbecility 
followed  the  disease  ;  perhaps  he  had  in  view  diphtheritic  paral- 
ysis ?  In  this  period,  pathological  anatomy  remained  stationary; 
the  question  on  all  sides  was  concerning  the  gangrenous  ulcers 
but  nothing  definite  about  the  false  membranes.  Autopsies 
were  wanting;  a  single  one,  however,  which  was  made  in  1642, 
demonstrated,  according  to  Severinus,  the  existence  of  a  false 
membrane  in  the  larynx.  In  1718,  Wolfgang  Wedel,  of  Jena, 
spoke  of  the  greater  frequency  of  contagious  angina  in  children 
in  Italy  when  compared  to  the  children  of  the  countries  in  the 
north  of  Europe.  He  gave  the  first  document  on  the  utility 
of  isolation  in  the  proph\'laxis  of  diphtheria  by  reporting  the 
history  of  a  father  who,  having  already  lost  five  children  by 
this  disease,  only  saved  the  sixth  by  quickly  removing  it.  In 
1735,  seventeen  years  after  the  epidemic  of  Naples,  Cadwalla- 
der  Colden,  Esq.,  announced  another  at  Kingston,  fifty  miles 
from  Boston,  in  the  United  States.  The  disease  attacked  children 
especially ;  changes  similar  to  those  in  the  back  part  of  the 
throat  were  often  observed  behind  the  ears,  upon  blistered  sur- 
faces, and  on  the  genital  organs.  Symptoms  of  croup  often 
supervened  and  terminated  the  scene.  We  find,  therefore,  in 
this  account  a  formal  mention  of  cutaneous  diphtheria.  France 
did  not  escape  the  epidemic  scourge  ;  it  prevailed  at  Paris  from 
1743  to  1748,  and  had  for  its  historians  Malouin  and  Chomel. 
The  latter  described  clearly  paralysis  of  the  velum  palati,  and 
a  case  of  diphtheritic  strabismus.     At  about  the   same   period 


40  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

Other  epidemics  arose  in  England  and  at  Cremona,  where  it  was 
studied  by  physicians  of  merit :  Fothergill,  Starr  and  Ghisi. 
The  angina  observed  by  Fothergill,  at  London,  was  secondary, 
and  connected  in  an  evident  manner  with  scarlatina ;  this  was 
probably  scarlatinous  diphtheria.  What  seems  to  confirm  this 
view  is  the  extreme  rarity  of  its  extension  to  the  air  passages. 
This  author  proved  the  inefficacy  of  blood-letting,  and  recom- 
mended deturgent  injections  and  aromatic  gargles.  The  dis- 
ease appeared  to  him,  moreover,  as  to  his  predecessors,  of  gan- 
grenous nature.  This  epidemic,-  of  which  Starr  gave  an  ac- 
count, raged  in  the  county  of  Cornwall.  It  was  much  more 
severe  than  that  of  London,  although  the  angina  was  primary. 
All  the  characteristics  of  malignancy  were  encountered ;  cervi- 
cal oedematous  swelling,  petechias,  generalization  of  the  false 
membranes,  anal  diphtheria,  extension  to  the  respiratory  pass- 
ages, and  pseudo-membranous  expectoration.  Ghisi  made  the 
same  observations,  but  in  addition  he  signalized  the  first  case 
of  primary  croup  without  angina ;  at  the  same  time  he  showed 
grangrenous  angina  alone,  then  these  two  affections  united  in 
the  same  patient,  and  considered  the  second  as  the  propagation 
of  the  first.  Like  his  predecessors  he  termed  the  disease  of 
the  posterior  part  of  the  mouth  and  throat,  ulceration  or  gan- 
grene. Moreover  he,  like  Chomel,  witnessed  certain  disturb- 
ances which  corresponded  to  diphtheritic  paralysis.  "  There 
is,"  said  he,  "  return  of  the  food  through  the  nose  and  a  nasal 
tone  of  voice,  persisting  for  a  shorter  or  longer  time  after  re- 
covery." In  1743,  Molloy  observed  an  epidemic  in  Ireland, 
reported  by  some  as  croup,  by  others  as  gangrenous  angina. 
In  1752,  diphtheria  appeared  in  New  York;  and  it  is  described 
by  Peter  Middleton,  who  mentions,  among  other  lesions,  false 
membranes  in  the  trachea.  It  was  noted  at  the  same  time  at 
Zurich  by  Langhans. 

From  175 1  to  1753,  Huxham  observed  an  epidemic  which 
prevailed  at  Plymouth.  The  angina  of  which  he  speaks  was 
secondary  in  a  large  number  of  cases ;  possibly  he  even  con- 
fused simple  scarlatinous  angina  with  diphtheria  of  the  same 
origin ;  but  he   pointed   out   some   cases  which   evidently  be- 


DIPHTHERIA.  4I 

longed  to  diphtheria :  there  were  present,  the  fetid  breath,  the 
rough,  hoarse  voice,  dyspnoea,  laryngo-tracheal  wheezing,  ejec- 
tions of  pseudo-membranous  patches,  and  diphtheritic  coryza. 
From  1755  Sweden  was  invaded  in  its  turn.  These  epidemics 
are  reported  by  Bergius,  Rudberg,  Schulz,  Hallenius,  Wilke, 
Wahlbom,  Bloom,  and  Engestroom.  In  several  of  the  epi- 
demics just  spoken  of,  it  is  proper  to  remark,  with  Deslandes, 
that  the  false  membranes  soon  lost  their  whitish  appearance 
and  became  brown,  black  and  fetid.  In  these  cases  one  would 
observe  adynamia,  nervous  phenomena,  offensiveness  of  the 
stools,  and  eruptions  of  the  skin ;  the  blood  furnished  by 
bleeding  was  slightly,  or  not  at  all,  coagulable.  In  other  epi- 
demics the  false  membranes  remained  white,  and  the  disease 
assumed  a  decided  benignity. 

In  France,  Marteau  de  Grandvilliers  gave  an  excellent  de- 
scription of  the  epidemic  at  Aumale.  He  described,  in  detail, 
a  case  in  which,  without  doubt,  the  diphtheria  was  com- 
plicated with  gangrene.  The  tracheal  and  laryngeal  false 
membranes  were  described  by  this  author  with  great  precision. 
He  gave  the  detailed  report  of  a  case  of  bronchial  diphtheria 
without  angina;  the  patient  ejected  ramified  false  membranes, 
which  were  illustrated  in  drawings.  We  also  mention  Dupuy 
de  la  Porcherie,  who  published  a  work  on  an  epidemic  of  gan- 
grenous angina,  which  raged  at  Charon  in  1762;  Van  Bergen 
who  observed,  at  Frankfort-on-the-Maine,  in  1764,  an  epidemic 
which  appeared  to  correspond  with  simple  croup  ;  and  Planchon, 
who  described  an  epidemic  occurring  in  1765  at  Peruwelz,  in 
Hainaut,  which  appeared  to  exist  especially  in  pultaceous  scar- 
latinous anginas.  In  the  same  year  appeared  the  celebrated 
work  of  Home ;  the  suffocative  affections  of  the  larynx  took 
the  name  of  croup,  by  which  it  has  ever  since  been  designated, 
and  was  minutely  described.  Several  preceding  authors  had 
signalized  the  laryngeal  symptoms  consecutive  to  angina  and 
even  primary  croup,  but  it  devolved  upon  the  Scotch  physician 
to  accurately  describe  what  the  others  had  vaguely  indicated. 
He  delineated  very  accurately  the  laryngeal  and  tracheal  false 
membranes.     This  lesion  failed  in  but  one  of  his  patients.     He 


42  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

located  the  seat  of  the  disease  in  the  cavity  of  the  air  pasages, 
and  attributed  the  production  of  the   false   membranes  to  con- 
cretion of  the  mucus.     Besides,  it  is  impossible  to  express  one- 
self more  clearly  than  Home  has  done  on  the  absence  of  gan- 
grene  in    croup.     "  The   practitioner,"  said   he,  "  who  has  had 
several  opportunities  for  post-mortem  examinations  in  this  dis- 
ease, will  be  much  more   inclined   to   the   belief  that   what  has 
been  regarded  as   gangrene   of  the    internal   membrane   of  the 
trachea,  is  only  a  false  membrane  become  black  in  consequence 
of  a  morbific  affection."      He    recognized   that  croup  attacked 
principally  children  from  two  to  twelve  years   old  ;  that  it  pre- 
vailed ordinarily  in  the  winter,  and  that  it  was  more  common  in 
damp  localities.     After  having   described   the   symptoms  with 
accuracy,   and    having    given    a    physiological    explanation    of 
them,  based  upon  the  structure  and  functions  of  the  larynx  and 
trachea,    he   closed   by   speaking   of  the   prognosis,    which  he 
based  upon  the  age  of  the  subject,  and  the  period  at  which  the 
treatment   was   commenced.     According   to   him,  the   medica- 
tions should  be  almost  exclusively  antiphlogistic  ;  lie  advises  in 
desperate  cases   the   operation  of  tracheotomy.      Home  is,  there- 
fore, the  real  inventor  of  the   word    croup.     Nevertheless,  it  is 
to  be  regretted   that,   while   seeing   solely  in   the   object  of  his 
description  a  new  disease,  he   separated   croup   distinctly  from 
the  angina  maligna  described  by  Aretaeus,  Mercado,  Sgambati, 
Huxham   and    Marteau.     He  could   not  recognize   that    croup 
and  angina  are  only  different  localizations  of  the  same  disease. 
Moreover  he  incurs   the   severe  censure,  from    Bretonneau,   of 
having   arrested   the   progress   of  observation,  and  hidden  the 
traces  of  ancient    traditions.     The    omission    of   Home,  expli- 
cable by  the  imperfection  of  science  at  his  time,  and  by  the  in- 
fancy of  pathological  anatomy,  is  compensated  for  by  the  def- 
inite addition,  to  the  nosological   list,  of  a   disease  but   imper- 
fectly apprehended  by  the  ancients.     It  had  the  unfortunate  re- 
sult of  separating  croup   from    diphtheria   for  a  long  time ;  the 
efforts   of  Bretonneau    succeeded    in    uniting    them    again,  not 
without  opposition  on  the  part  of  a  certain   number  of  physic- 
ians.    It  served,  again,  as  a  pretext  to  the  recent  attempts  made 


DIPHTHERIA.  43 

in  Germany  to  renew  the  divorce  between  these  two  morbid 
conditions.  On  the  other  hand,  while  croup  was  better  studied, 
gangrenous  angina  remained  where  Marteau  de  GrandvilHers 
left  it.  Deslandes  shows  us  at  what  point  the  chaos  occurred  in 
this  matter.  "  The  separation  of  croup  and  angina  gangrenosa 
did  not,  however,"  said  he,  "  remove  from  the  latter  the  symp- 
toms of  croup ;  it  preserved  them  all  until  now,  so  that  the 
works  on  pathology  describe  them  twice  under  two  different 
titles."  In  1769,  Millar  endeavored  to  distinguish  laryngeal 
asthma  from  croup ;  he  showed  that  this  asthma  is  not  accom- 
panied with  plastic  expectoration  nor  with  swelling  of  the  neck. 
In  the  midst  of  this  agreement  but  two  protestations  are  heard, 
that  of  Keettel  and  that  of  Samuel  Bard.  The  former,  in  1769 
and  1770,  observed  an  epidemic  of  angina  which  he  named 
strangulatoria  :  at  one  time  this  disease  is  limited  to  the  phar- 
ynx, at  another  it  extends  into  the  trachea.  In  1771,  Samuel 
Bard,  of  New  York,  who  was  the  true  forerunner  of  Bretonneau  ; 
like  Ghisi  and  as,  later,  the  celebrated  physician  of  Tours, 
had  the  good  fortune  to  observe  angina  alone,  angina  in  unison 
with  laryngitis,  and  laryngitis  alone.  He  reported  observations 
of  the  different  forms  which  he  considered  as  all  three  being  of 
the  same  nature.  He  established  the  identity  of  the  affection 
which  he  observed  with  that  of  Home,  and  with  the  epidemic 
disease  which  Aretaeus  and  the  Spanish  and  Italian  physicians 
described.  For  him,  angina  was  not  a  gangrenous  affection ; 
and  he  regarded  the  patches  as  formed  of  concreted  mucus 
produced  by  an  alteration  of  the  glands  of  the  naso-pharyn- 
geal  space  and  of  the  trachea ;  they  remain  white,  or  become 
putrid,  according  to  their  age  or  the  nature  of  the  patients.  He 
found  in  one  of  his  autopsies,  inflammation  of  the  lungs  "  such 
as  follows  peripneumonia."  Cutaneous  diphtheria  was  also 
seen  by  him  ;  several  of  his  patients  were  attacked  with  it  be- 
hind the  ears.  Consecutive  paralysis  was  signalized  also  by 
him  ;  in  one  patient  it  produced  dysphagia,  aphonia,  and  diffi- 
culty in  walking.  The  ideas  of  Bard  found  no  response  except 
some  authors,  such  as  Solomon  and  Boeck,  who  made  obser- 
vations at   Stockholm,  in    1772;    Zobel,  at   Werth,  near  Ratis- 


44  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

bonne,  and  Bayley  (1774 — 79);  with  the  exception  of  these  au- 
thors, all  those  who  wrote  after  Bard  saw  or  believed  they  saw 
only  simple  croup.  Besides,  we  should  mention  Crawford,  of 
Scotland  (1771),  and  Michaelis  (1778),  who  reproduced  the 
ideas  of  Home  and  gave  the  disease  the  name  of  angina  poly- 
posa  seu  membranacea.  In  1783  the  Royal  Society  of  Medi- 
cine of  France  offered  a  prize  on  the  subject  of  croup,  and  re- 
warded the  memoir  of  Vieusseux  of  Geneva.  This  author  de- 
scribes three  varieties  of  croup  :  the  inflammatory,  the  nervous 
and  the  chronic.  From  this  time  until  the  prize  awarded  in 
1807  by  Napoleon  I.,  a  great  number  of  authors  wrote  on  croup; 
Borsieri,  Stoll,  Reil,  Girtanner,  and  Schwilgue,  to  whom  science 
is  indebted  for  the  editing  of  the  materials  collected  by  the 
Ecole  de  Medicin,  for  the  grand  prize  of  1807.  The  result  of 
this  contest  is  known.  Of  the  seventy-nine  memoirs  only  five 
were  rewarded :  Jurine,  of  Geneva,  and  Albers,  of  Bremen,  di- 
vided the  premium  ;  Vieusseux,  Caillau  and  Double  received 
honorable  mention.  Royer-Collard,  in  a  report  which  remains 
a  scientific  monument,  analyzed  and  criticised  the  works  of  the 
successful  candidates.  Jurine  distinguished  himself  over  his 
contemporaries  by  recognizing  that  croup  often  complicated 
malignant  angina  of  children.  Moreover  he  expressed  the  most 
decided  doubts  upon  the  gangrenous  nature  of  this  angina. 
The  following  passage,  borrowed  from  his  manuscript  and  al- 
ready cited  by  Barthez  and  Rilliet,  furnishes  the  proof  of  it : 
"  There  is  another  disease,  epidemic  and,  perhaps,  contagious, 
with  which  croup  is  ordinarily  complicated,  and  which,  in  some 
respects,  resembles  ordinary  gangrenous  angina,  while  it  differs 
from  it,  sensibly  enough  in  others,  to  claim  the  attention  of 
physicians;  the  disease  is  angina  gangrenosa  of  children.  When 
one  reads  the  works  of  authors  who  have  described  the  symp- 
toms of  this  disease,  and  reflects  upon  the  predisposition  that 
children  have  to  take  the  disease,  the  promptness  with  which 
the  concretion  is  formed  in  the  trachea,  the  nature  of  the  spots 
or  ulcers  which  cover  the  tonsils  and  the  walls  of  the  pharynx, 
and,  finally,  upon  its  termination,  one  experiences  a  feeling  of 
uncertainty  concerning  the  existence  of  gangrene  in  the  major- 


DIPHTHERIA.  45 

ity  of  cases  of  angina,  so  that  one  would  be  tempted  to  sup- 
pose that  it  is  only  croup  itself,  disguised  by  the  putrid  in- 
fluence of  the  epidemic,  and,  consequently,  to  name  it  putrid, 
malignant,  or  aphthous  croup."  These  ideas  passed  unheeded 
and  were  held  as  null  and  void  like  those  of  Bard.  After  the 
prize  of  1807,  a  certain  number  of  works  were  published, 
among  which  we  may  cite  those  of  Vallantine,  Royer-Collard, 
Desruelles,  des  Essarts,  Blaud,  of  Beaucaire,  Double  and  Brich- 
eteau.  These  authors  continued,  as  was  formely  done,  to  re- 
gard angina  and  croup  as  two  distinct  diseases.  More  than 
ever,  the  gangrenous  nature  of  angina  was  entertained  when 
Bretonneau  appeared.  The  illustrious  physician  of  Tours  gave 
his  support  to  the  ideas  of  Samuel  Bard  ;  he  proved,  in  the  most 
positive  manner,  the  identity  in  nature  of  the  different  pseudo- 
membranous inflammations  of  the  mucous  and  cutaneous 
structures  designated  up  to  that  time  by  the  names  angina 
gangrenosa,  croup,  ulcers,  etc.  He  taught  that  these  different 
morbid  states  were  only  different  manifestations  of  one  and  the 
same  disease  which  he  introduced  into  nosology  under  the 
name  of  diphtherite,  from  dofOipa,  membrane.  He  demon- 
strated irrefutably  the  absence  of  gangrene  in  the  form  of  an- 
gina called  gangrenosa.  He  separated  distinctly  from  croup 
an  affection  which  was  generally  confounded  in  France  with 
pseudo-membranous  laryngitis,  viz.,  the  disease  first  described 
by  Millar  under  the  name  of  asthma ;  it  received  from  Breton- 
neau the  name  of  laryngitis  stridulosa,  then  from  Guersant  that 
of  pseudo  croup,  and  that  of  spasmodic  laryngitis  from  Bar- 
thez  and  RiUiet.  To  crown  his  work,  Bretonneau  had  the  dis- 
tinguished merit  of  restoring  tracheotomy  to  repute.  The  ep- 
idemics of  Tours  (1818),  of  Ferriere  (1825)  and  of  Chenusson 
(1826),  furnished  him  the  materials  for  his  work.  The  novelty 
of  the  work  of  Bretonneau  appeared  in  the  methods  which  he 
adopted.  Contrary  to  his  predecessors,  to  begin  with,  he  based 
his  arguments  almost  exclusively  upon  pathological  anatomy. 
Adopting  the  ideas  of  Laennec,  he  recognized  that  diseases  can 
be  definitely  distinguished  only  by  their  anatomical  character- 
istics.    He  omitted  nothing,  neither  the  chemical  analysis,  nor 


46  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

even  the  microscopical  examination.  These  researches  led  him 
to  the  conclusion  that  the  so-called  eschar  was  nothing  other 
than  the  product  formed  at  one  time  from  thickened  mucus,  at 
another  from  fibrine  exuded  by  the  inflamed  mucous  membrane; 
he  proved,  what  had  never  been  clearlyestablished,  the  continuity 
of  the  false  membranes  of  the  larynx  and  of  the  trachea  with 
those  of  the  throat  and  nasal  fossae.  It  was  not  enough  to 
show  these  productions  as  the  result  of  an  inflammation  of  the 
mucous  membrane,  Bretonneau  had  the  inspiration,  so  prolific, 
of  the  specificity.  It  is  with  the  following  announcement  of 
principles  that  the  book  begins :  "  The  illustrious  author  of 
Philosophical  Nosography  [Pinel],  in  taking  for  a  basis  of  his 
classification  of  phlegmasiae,  the  modifications  which  inflamma- 
tion undergoes  in  the  diverse  organic  tissues,  has  certainly  shed 
new  light  on  a  large  number  of  diseases  and  given  a  new  impulse 
to  the  spirit  of  observation.  Still,  one  is  forced  to  acknowledge 
that  the  diversity  of  the  inflammatory  alterations,  and  that  of 
the  phenomena  with  which  they  are  accompanied  can  not  de- 
pend upon  this  single  condition.  The  specific  character  of  in- 
flammation, rather  than  its  intensity  or  the  nature  of  the  tissue 
of  which  it  is  the  seat,  influences  the  disturbance  which  every 
inflammatory  lesion  produces  upon  the  functions.  It  is  the  spe- 
cificity of  the  inflammation  with  which  the  duration,  the  grav- 
ity and  the  danger  of  the  majority  of  fevers  correspond.  No 
tissue,  perhaps,  is  susceptible  of  a  single  form  of  inflammation; 
but  the  diverse  inflammations  with  which  the  external  tegument- 
ary  envelope  may  be  affected,  present,  without  doubt,  the  most 
manifold  and  remarkable  differences.  Should  one  direct  the 
least  attention  to  it  he  will  also  be  convinced  that  the  mucous 
tissue — the  internal  tegumentary  organ,  is  also  the  seat  of  in- 
flammations extremely  diversified."  And,  further,  "  I  should 
not  express  all  my  thoughts  if  I  did  not  add,  that  I  see  in  this 
membranous  inflammation  a  specific  phlegmasia  as  different 
from  a  catarrhal  phlogosis  as  malignant  pustule  is  from  zona,  a 
disease  more  distinct  from  scarlatinous  angina  than  scarlatina 
itself  is  from  chicken-pox  ;  finally,  a  morbid  affection  sui  ge7ie- 
ris,  which  is  no  more  the  last  expression  of  catarrh  than  squam- 


DIPHTHERIA.  4/ 

ous  dartre  is  the  last  termination  of  erysipelas.     In  the   impos- 
sibility of  applying  to  a  special  inflammation  so  decided,  a  sin- 
gle one  of  the  improper  names  which  has   been   given  to  each 
of  its  shades,  I  may  be  permitted  to  distinguish    this  phlegma- 
sia under  the  name  of  Diphtherite,  derived  from  ^KfOipa,   "pel- 
Its,    exuviuni,   vestis  coriacea,    whence    St<fOtii<'io>,    corio    obtcgo." 
Immediately  on  their  appearance  the  ideas  of  Bretonneau  found 
numerous  supporters  :  Guersant,  Louis,  Tobanon  and  MacKen- 
zie  added  also  their  testimony.    But  the   most   powerful   cham- 
pion to  Bretonneau,  the  most  eloquent  popularizer  of  his   doc- 
trine, beyond   question,  was   Trousseau,   his   pupil   and   friend. 
Not  only  was  Trousseau  the   successor  of  Bretonneau,  but  he 
completed  the  latter's  doctrine,  improved  it,   and  brought  it  to 
the  point  where  we   find   it   to-day.     Investigating   the   idea  of 
specificity,  he  showed  that  if  diphtheria  is  a  specific,  it  is  so  not 
only  so  far  as   the   inflammation   producing  the   patch  is  con- 
cerned, but  as  a  general  disease,  totius  substantice,  unique  in   its 
nature,    infectious,  and   possessing   the   property  of  causing  at 
different   points   of  the   economy,   inflammations   the   result  of 
which  is  false  membranes.     To  his  mind  the  inflammation  was 
no  longer  an  initial  but  a  secondary  phenomena.     Bretonneau 
thought  that  diphtheria  destroyed   by   suffocation.     Trousseau, 
however,  showed  that  this  condition  was  not  necessary,  but  that 
the  disease  itself  produced  death,  by  infection  of  the  organism, 
without  intervention  of  asphyxia.     To  express  this    conception, 
he  modffied  the  nosological  term  created  by  Bretonneau  :  from 
diphtheritis  he  formed  diphtheria.     Finally,   he  gave  a  strong 
impulse  to  tracheotomy  by  improving  the  operative   procedure 
and  the  after  treatment,  and  by  rendering  the  recoveries  numer- 
ous, which  until  then  were  exceptional.     From  this  time  on,  the 
works  on  this  subject,  as  well  in  France  as  abroad,  became  very 
numerous.     In  France,  the  views  of  Trousseau  were  universally 
accepted,  except  upon  some   points,  of  which   we   shall   speak 
hereafter.     England  has  given  up  (or   renounced)  the  views  of 
Home ;  deadly  epidemics  of  infectious  diphtheria  gave   to  the 
disease,  according  to  West,   a   form  very   nearly   similar   in  the 
two  countries.     Portugal,  Spain,  Italy,  nearly  all   the   countries 


48  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

of  Europe,  and  of  the  New  World,  have  adopted  Trousseau's 
views.  It  is  not  so  in  Germany.  Regarding  diphtheria  from  a 
purely  anatomical  standpoint  and  holding  the  results  of 
clinical  observations  as  valueless  (null  and  void),  Virchow, 
Wagner,  Rokitanski  and  their  school  caused  science  to 
relapse  into  the  chaos  from  which  Bretonneau  rescued  it. 
Returning  to  the  theories  of  Home,  they  separate  angina  and 
croup  in  the  name  of  pathological  anatomy.  The  former  was 
again  regarded  as  a  gangrene ;  the  latter  only  was  regarded  as 
of  an  exudative  nature.  The  first  was  held  to  be  infectious ; 
the  last  as  simply  inflammatory.  The  succession  of  croup  to 
angina  was  explained  by  saying  that  the  two  diseases  so  differ- 
ent, might  exist  side  by  side  in  the  same  patient.  This  dis- 
tinction appeared  even  so  fortunate  that  the  two  names,  diph- 
theria and  croup,  employed  up  to  that  time  to  designate  the 
morbid  totality,  was  applied  exclusively  to  anatomical  processes. 
Diphtheria  was  applied  to  every  lesion  consisting  in  fibrinous 
infiltration  of  the  tissues ;  while  croup  was  used  to  signify  all 
anatomical  alterations  characterized  by  a  superficial  fibrinous 
exudation.  Thus  it  is  that  ulcero-membranous  stomatitis,  which 
has  absolutely  nothing  in  common  with  diphtheria,  understood 
in  its  correct  acceptation,  is  a  diphtheria  in  the  German  sense, 
and  that  a  croupal  pneumonia  has  been  instituted,  on  the  pre- 
text that  this  disease  had,  as  its  anatomical  product,  an  exuda- 
tion of  fibrine  on  the  surface  of  the  pulmonary  vesiculae.  I 
shall  enlarge  more  fully  upon  these  speculations  in  order  to 
combat  them,  aided  besides  in  the  task  by  several  German  au- 
thors who  seem  to  have  gained  anew  a  glimpse  of  the  truth. 
In  spite  of  these  divergencies,  the  dogma  of  specificity,  and  of 
the  unity  of  diphtheria  is  confirmed  ;  the  contagiousness  of  the 
disease  has  been  demonstrated,  its  complications  and  its  se- 
quences have  been  studied  ;  the  treatment  has  been  improved, 
and  tracheotomy  is  now  largely  practised  in  many  countries 
where  it  renders  every  year  increased  service.  For  a  moment 
led  astray  by  these  Germanic  notions,  the  physicians  of  all 
countries  are  returning  to  the  doctrine  of  Bretonneau  and 
Trousseau.     Numerous  works  have  thrown   light  upon   differ- 


DIPHTHERIA.  49 

ent  parts  of  the  subject.  At  the  head  of  the  list,  I  should  men- 
tion that  of  Deslandes,  which  appeared  in   1827,  a  remarkable 
work,  in  which  the  history  of  diphtheria  is  treated  from  its  ori- 
gin very  fully  and  in   the   most  judicial   spirit   of  criticism.     I 
have  been  fortunate  in  finding  a  guide  so  safe  on  a  question  so 
complex.    Bretonneau  went  too  far  in  excluding  absolutely  gan- 
grene from   diphtheria ;  protestation  arose :  de   la  Berge,   and 
Monneret,  Becquerel,   Barthez  and   Rilliet,   Gubler,   Isambert, 
Crequy,  Millard,  Axenfeld  and  others  cited  indisputable  exam- 
ples   of    the    coincidence    of    gangrene   with    diphtheria,    and 
showed  that  while  diphtheria  was  not  gangrene,  these  two  pro- 
cesses might  co-exist.     Recent  epidemics  have  been  observed 
by  Guimier  (1826-7),   ^.t  Vouvray;  Gendron  (1829),   at  Ven- 
dome    and    at   Artlns    (Loir-et-cher) ;    Lespine    (1830),    at    la 
Fleche;  Ridard  (1832),  at  Bohalle;  Bourgeois  (1827-8),  at  St. 
Denis;  Boudet  (1842)  and  Becquerel  (1843),  at  Paris;  Daviot 
(1841-2),  in  the  department  of  the  Saone-et-Loire  and  Nievre ; 
Gibbon    (1845),    at    Salem,    U.S.;    Lespiau    (1854),    Oulmont 
(1855),  at  Paris;  Besnard,   Fourgeaud  (1856-7),  in   California; 
Forgeot  (1857),  at  Vignory;  Bouillon   Lagrange   (1857-8),   in 
the  department  of  the  Saine-et-Oise;  Peter  (1858),   at  Paris; 
Robert  (1859),  in  the  Lower  Charente;  Saint-Laurent  (i860), 
at  Paris;  Jugand  (1856,  7,  8-9),  at  Issoudun ;  Landeau   (1861), 
in  the  vicinity  of  Bordeaux ;  Bricheteau  (1859),  at  Paris  ;  Brown 
(1862),  in  United  States;  Radcliffe  (1862),  in  England;  Wynne, 
from    1855    to    1861,   in   England;   Kohnemann  (1862),  in  the 
island  of  Baltrum ;  Wiedash  in  1862  in  the  island  of  Nordeney; 
Forster,  from  1862  to   1864,  at   Prague;    Uhlenburg,    at    Leer, 
Germany;  Tuefferd,  of  Montbeliard  (1864),  at   Etupes;  Nivet, 
from  1849  to    1865,  in   Clermont — Ferrand;  Guillemant,   from 
1863  to  5^1865,  at  Louhans;  Van  Capelle  (1864),  in    Holland; 
Demme  (1868),  at  Berne ;  Marmisse,  from  1858  to  1866,  at  Bor- 
deaux; Dillie  (1866),  at  Arnemuiden,  in  Holland;  Becker  (1866) 
in  Hanover;  Bartels  (1866),  at  Kiel;  Henroz,  at  Bihain,  Bel- 
gium; Lange  (1865),  Ditzel  (1869),  in  Denmark;  Graf  (1868), 
at  Munich  ;  Felix  (1868),  at  Bucharest ;  Gaupp  (1868),  at  Schorn- 
dorf,  Wurtemburg;  Mair  (1871),  in  Middle  Franconia ;  Flam- 


50  DIPHTHERIA,    CROUP   AND    TRACHEOTOMY. 

marion  —  Haut-Marne  (1871-2);  Nesti,  from  1862  to  1872, 
at  Florence;  Binder,  at  Agnetheln,  in  Transylvania  (1873); 
Otrobon,  from  1870  to  1873,  in  Transylvania. 

The  structure  of  the  false  membranes  and  their  chemical 
composition,  sketched  by  Bretonneau,  then  indicated  more 
fully  by  Thompson,  have  been  the  subject  of  very  important 
studies,  especially  in  Germany.  Albuminuria,  diphtheritic  ex- 
anthemata, pulmonary  complications  and,  quite  recently, 
lesions  of  the  circulation,  as  well  as  consecutive  paralysis,  have 
furnished  material  for  numerous  works,  as  well  in  France  as  in 
other  countries,  and  for  important  discussions  at  sessions  of 
learned  societies. 

The  treatment  of  diphtheria  has  been  examined  in  all  its 
phases ;  local  applications  by  caustics  and  astringents,  submit- 
ted to  a  severe  control,  have  lost  much  of  their  importance. 
Persons  have  been  much  occupied  in  seeking  for  agents  capa- 
ble of  dissolving  the  false  membranes  without  injuring  the 
healthy  tissues. 

Controstimulants,  then  tonics  have  been  applied  to  diphthe- 
ria; efforts  have  even  been  made  to  find  a  specific  for  it.  Trach- 
eotomy especially  has  been  subjected  to  violent  attacks.  The 
discussion  on  catheterism  of  the  glottis,  prolonged  in  1858  be- 
fore the  Academy  of  Medicine,  and  before  the  Societe  des  Hopi- 
taux  of  Paris,  will  remain  memorable.  Defended,  notably  by 
Trousseau  and  by  Bouvier,  with  extraordinary  talent,  the  oper- 
ation (tracheotomy)  repulsed  victoriously  the  unjust  attacks.  At 
this  debate,  the  periods  of  croup  were  defined  by  Barthez,  who 
insisted  upon  the  part  which  the  infectious  element  played  in  the 
failures  of  tracheotomy.  He  pointed  out  the  impropriety  of  plac- 
ing side  by  side  in  the  statistics  the  cases  of  infectious  croup  and 
cases  without  apparent  infection,  showing  that  the  comparison 
between  analogous  cases  alone  can  furnish  precise  results. 

Numerous  modifications  have  been  proposed  for  the  opera- 
tive procedure,  and  numerous  instruments  have  been  invented ; 
the  expeditious  method  has  been  recommended  as  more  advan- 
tageous than  the  slow  method,  advocated  by  Trousseau.  Can- 
ulas  of  all  sorts  have  been   constructed,  while   certain  authors 


DIPHTHERIA.  5 1 

have  proposed  to  dispense  with  this  instrument.  The  indica- 
tions and  the  contraindications  of  the  operation  have  been  ex- 
amined at  different  times,  and  gave  rise,  especially  in  1807,  to 
an  interesting  discussion  before  the  Societe  Medical  des  Hopi- 
taux,  of  Paris.  The  contraindications  have  diminished.  The 
after  treatment  of  the  operation,  brought  into  prominence  by- 
Trousseau,  has  attained,  in  the  minds  of  physicians,  the  im- 
portance that  it  merits.  Millard  has  treated  this  question  in  a 
remarkable  work.  I  have  in  a  previous  work  set  forth  this 
part  of  the  subject  as  well  as  the  accidents  following  the  oper- 
ation. We  note  also  the  ulcerations  of  the  tracheal  tube,  on 
which  Roger  presented  an  important  communication  to  the 
Societe  des  Hopitaux.  In  his  last  clinical  lectures.  Trousseau 
completed  his  conception  of  the  unity  and  the  specificity  of 
diphtheria.  Barthez,  in  different  writings,  entered  into  the  same 
ideas. 

The  current  which  has  impelled  science  for  the  last  few  years 
to  seek,  in  diseases,  and  particularly  in  epidemics,  for  low  or- 
ganisms should  have  like  results  in  respect  to  diphtheria.  We 
have  demanded  of  a  parasite  the  secret  which  the  disease  still 
keeps  of  its  origin  and  of  its  mode  of  propagation.  Advanced 
by  Jodin,  this  idea  was  not  slow  in  finding  partisans,  principally 
in  Germany.  According  to  Hallier,  Biihl.  Jaffe,  Hueter  and 
Tommasi,  and  Eberth,  diphtheria  has  become  a  zymotic  disease. 
Recently,  Letzerich  has  built  upon  this  principle  a  complete 
theory.  Other  observers.  Senator  in  particular,  have  demon- 
strated the  error  of  the  former  authors,  and  showed  that  the  so- 
called  diphtheritic  parasites  are  only  developed  on  false  mem- 
branes already  old  and  altered.  A  great  number  of  foreign 
works  have  been  published  on  diphtheria.  Germany  has  re- 
served to  itself  principally  the  pathological  anatomy ;  England 
has  been  occupied  particularly  with  diphtheritic  paralysis,  and 
Portugal  has  furnished  us  some  very  remarkable  clinical  works. 
These  researches  will  be  brought  into  prominence  when  I  shall 
examine  the  part  of  diphtheria  to  which  they  belong.  I  shall, 
however,  mention  the  principal  ones,  those  of  Antonio  Maria 
Barbosa,  of  Lisbon ;  Bartels,  of  Kiel,  and  Senator. 


PATHOLOGICAL    ANATOMY. 


Diphtheria,  a  general,  septic  aisease,  even  in  its  mildest 
forms,  leaves  its  impression  upon  every  part  of  the  economy — 
no  apparatus  escapes  its  attacks.  The  lesions  which  it  pro- 
duces are  multiple,  and  should  be  sought  for  in  every  organ. 
There  is  one  lesion,  however,  which  attracts  attention  and  ex- 
ceeds all  others.  (To  that  alone,  which  characterizes  the  mal- 
ady and  gives  it  its  special  stamp,  I  give  the  name  of  false 
membrane).  The  other  alterations,  though  important  and  in- 
teresting in  so  many  respects,  pass  to  the  second  rank ;  they 
are  no  longer  essential.  One  or  more  of  them  may  fail  from 
the  picture,  then  it  looses  some  of  the  additions,  but  the  prin- 
cipal subject  stands  out  in  no  less  distinctness  and  strength.  It, 
therefore,  follows  that  the  lesions  of  diphtheria  should  be  di- 
vided into  two  general  classes  : 

The  first  will  comprehend  \\\&  fundamental  ox  primary  lesions, 
that  is,  the  false  membrane  and  the  alterations  of  the  tissues 
which  underlie  it.  This  will  be  the  general  pathological  anato- 
my of  diphtheria. 

The  second  will  comprise  lesions  of  apparatus  which,  aside 
from  the  false  membranes,  are  met  with  in  subjects  attacked 
with  diphtheria,  and  may  be  attributed  to  the  influence  of  this 
disease.     These  are  the  secondary  lesions. 

FIRST     CLASS  — PRIMARY     LESIONS. 


Section  I.     The  False  Membrane. 


The  diphtheritic  pellicle  presents  for  study:  Its  external 
characteristics,  its  structure,  chemical  composition,  and  its  evo- 
lution. 

(52) 


PATHOLOGICAL    ANATOMY.  53 

I. EXTERNAL    CHARACTERISTICS. 

Seat. — All  the  mucous  membranes  and  the  entire  cutaneous 
surface  are  liable  to  become  the  seat  of  false  membranes. 
An  exception  may  be  made  of  mucous  membranes  protected 
from  the  air ;  the  presence  of  diphtheritic  exudations  on  their 
surface  is  very  rare,  and  it  has  even  been  positively  denied,  but 
incorrectly. 

Form. — The  product  of  diphtheria  is  spread  upon  the  sur- 
faces in  the  form  of  patches  or  pellicles  of  variable  appearance, 
but  roughly  resembhng  adventitious  membranes,  hence  the 
name,  false  membrane.  The  exudation  is  limited,  occasionally, 
to  a  single  patch ;  ordinarily  several  exist,  occupying  at  one 
time  the  same  region,  at  another  different  points.  In  the  same 
locality  their  number  often  corresponds  with  the  period  in  the 
disease ;  small,  and  separated  in  the  beginning  by  healthy  tis- 
sue, they  increase  and  become  united  later. 

Usually  they  are  somewhat  round  and  their  borders  regular. 
These  characteristics,  however,  are  not  constant.  The  age  of 
the  disease  and  its  seat  affect  the  form  of  the  product ;  it  is  es- 
pecially in  the  throat  and  in  the  mouth  that  it  is  rounded  in  the 
beginning;  later,  the  edges  are  irregular,  and  excavated  into 
irregular  flaps.     The  form  varies  also  according  to  the  regions. 

Upon  the  skin  they  are  large  patches  with  sinuous  margins ; 
in  the  Eustachian  tube  the  false  membrane  is  accurately 
moulded  to  this  duct ;  in  the  nasal  fossae  it  conforms  to  the  tur- 
binated bones ;  in  the  respiratory  passages  it  presents  irregular 
patches,  and  incomplete  or  complete  straight  tubes,  or  dichoto- 
mously  ramified  (see  plate  of  cast  opposite  the  frontispiece);  in 
the  oesophagus  and  stomach  it  forms  long  strips ;  and  about  the 
anus  it  is  found  in  patches,  remote  or  near,  and  sometimes  it 
ascends  into  the  rectum. 

Dimensions. — They  vary  infinitely  from  a  millet-seed,  or  ves- 
icles of  guttural  herpes,  or  tonsilar  concretions,  to  those  of  broad 
patches  occupying  the  posterior  surface  of  the  trunk  from  the 
nucha  to  the  sacrum.  They  increase  as  the  disease  becomes 
older.     Sometimes,  however,  the  punctiform  false  membranes 


54  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

persist  in  these  limited  dimensions  during  the  entire  period 
of  their  evolution. 

Surfaces — Superficial  and  Deep. — The  superficial  surface  is 
smooth,  moderately  elevated  at  the  centre  and  becomes  atten- 
uated at  the  margins,  which  appear  to  be  continuous  with  the 
substratum  when  the  patch  is  small  and  recent.  When  it  is 
older  and  beginning  to  be  detached,  the  margins  retract  and 
become  elevated.  If  the  exudate  covers  a  wide  surface,  the 
central  prominence  disappears.  The  surface  is  sometimes 
ridged  and  grained,  mainly  when  the  false  membrane  is  old. 

The  deep  surface  is  less  even,  it  is  often  ridged  or  villous  and 
velvety ;  it  receives  the  impression  of  the  parts  which  it  covers. 
Sometimes  it  gives  rise  to  filaments  which  correspond  to  the 
orifices  of  the  mucous  glands.  When  the  exudate  is  recent  it 
is  very  adherent  to  the  subjacent  tissue,  and  is  detachable  only 
in  particles,  and  causes  bleeding  of  the  parts ;  when  older,  its 
adherence  diminishes  and  the  membrane  falls  off  of  itself. 

Color. — From  white  at  first  to  opaline,  then  often  to  yellow- 
ish, the  superficial  surface  contrasts  strongly  with  the  red  color 
of  the  inflamed  mucous  membrane  and  the  ulcerated  surfaces ; 
not  infrequently  it  becomes  grayish.  It  may  assume  a  tint 
deep  gray  or  brown,  which  gives  it  the  aspect  of  an  eschar. 
Ancient  authors,  struck  by  this  appearance,  believed  in  the  ex- 
istence of  a  gangrenous  process,  hence  the  name,  gangrenous 
ulcer  and  angina  gangrenosa.  Brettonneau  opposed  with  all 
his  influence  this  identification ;  he  maintained  the  constant  in- 
tegrity of  the  mucous  membrane,  and  refused  to  regard  the 
deep  discoloring  of  the  membrane  as  anything  more  than  the 
result  of  sanguineous  imbibition,  a  common  occurence  in  diph- 
theria. He  was  wrong,  however,  in  excluding  gangrene  en- 
tirely ;  under  some  circumstances  it  really  does  accompany 
diphtheria.  The  deep  surface  is  usually,  in  the  beginning,  of  a 
rather  deeper  shade  than  the  other,  and  has  little  bloody, 
reddish,  or  ecchymotic  spots,  which  subsequently  disappear. 

Thickness. — In  thickness  it  is  variable,  at  one  time  reduced 
to  a  thin  white,  semi-transparent  pellicle,  having  quite  the  ap- 
pearance  of  the  vitelline  membrane  of  the   Qgg\  at  another, 


PATHOLOGICAL    ANATOMY.  55 

quite  considerable,  formed  of  several  stratified  layers,  and  may- 
exceed  two  millimetres.  Then  it  is  that  it  has  that  resemblance 
to  the  membrane  or  skin  of  lard  which  attracted  the  first  ob- 
servers. Generally  speaking,  the  thickness  attains  its  maxi- 
mum in  the  throat  and  in  the  larynx,  especially  in  the  ventri- 
cles; it  diminishes  to  its  minimum  in  the  bronchial  tubes.  It 
is  especially  upon  the  tonsils  that  the  false  membrane  becomes 
abundant ;  in  the  bronchial  tubes  it  becomes  attenuated  and 
terminates  in  thin  strips.  Nevertheless,  I  have  seen  croup 
patients  expel  pseudo-membranous  fragments,  very  thick  and 
consistent,  coming  from  the  trachea.  In  these  cases,  the  dis- 
ease had  existed  for  a  long  time,  and  several  fibrous  layers  were 
super-posed. 

Consistence. — This  is  in  proportion  to  the  thickness.  Ordi- 
narily compact  and  elastic,  it  may  acquire  a  firmness  and  re- 
sistance almost  cartilaginous.  Such  is  the  false  membrane  in 
its  acme,  at  the  moment  of  its  complete  development.  At  the 
beginning,  the  stage  of  formation,  it  is  soft,  dififiuent;  later, 
when  it  reaches  the  end  of  its  evolution,  it  may  soften  and  be- 
come pulpous. 

Odor. — The  false  membrane  is  odorless  by  itself;  one  must 
not  attribute  to  it  the  exhalations  which  proceed  from  the  al- 
terations of  the  epithelium  and  the  buccal  liquids,  blood  and 
mucus.  One  will  observe  that  the  stale  and  nauseous  odor  of 
diphtheritic  angina  is  not  perceived  at  first,  but  is  in  the  course  of 
a  few  days,  when  a  bloody  exudation  occurs  on  the  surface  of 
the  mucous  membrane,  and  when  the  false  membrane  commences 
to  disintegrate.  In  the  infectious  form  of  anginas,  grave  altera- 
tions of  the  mucous  membrane  as  well  as  a  strong  disposition 
to  putrefaction  are  occasionally  added  to  the  above  causes. 

II. STRUCTURE. 

From  Bretonneau  down  to  the  last  few  years  the  false  mem- 
brane of  diphtheria  was  considered  as  a  pellicle  produced  by 
exudation  on  the  surface  of  the  inflamed  mucous  membrane  by 
virtue  of  the  same  action  as  in  the  false  membrane  of  the  pleura, 
and  leaving  the  subjacent  membrane  intact.  While  the  ancients 


56  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

held  to  the  existence  of  a  gangrenous  process  in  all  grave  cases 
of  angina,  Bretonneau,  falling  into  the  opposite  extreme,  de- 
nied emphatically  all  change  in  the  mucous  membrane.  A  re- 
action was  not  long  in  rising  against  this  too  exclusive  opinion. 
Some  observers,  less  prejudiced,  Becquerel,  Barthez  and  Ril- 
liet ;  e'^en  Trousseau,  Laboulbene,  Roger  and  Peter,  and  Isam- 
bert,  1  ^ognized  the  undeniable  existence  of  lesions  of  the  mu- 
cous nembrane  in  certain  infectious  or  secondary  anginas. 
While  retaining  for  the  false  membrane  of  benign  diphtheria 
the  characteristics  and  mode  of  formation  which  Bretonneau 
assigned  to  it,  they  attribute  the  alterations  of  the  mucous  mem- 
brane to  the  secondary  or  infectious  forms  which  are  so  fre- 
quently coincident.  The  work  performed  in  recent  years  by 
the  German  school,  under  the  direction  of  Virchow,  goes  still 
further.  Denying  to  the  diphtheritic  false  membrane  its  exu- 
dative character,  these  authors  have  been  principally  engaged 
in  demonstrating  that  it  was  solely  constituted  by  a  morbid 
transformation  of  the  mucous  membrane  which  formed  of  it  a 
veritable  eschar.  This  theory  reigned  supreme  for  several 
years,  but  its  halo  is  beginning  to  fade.  Opponents  have 
arisen,  and  by  a  singular  revolution  their  researches  have  restored 
to  light  the  old  theory  of  Bretonneau,  modifying  it,  however,  a 
little. 

These  vicissitudes  I  shall  now  examine.  Writers,  previous 
to  Samuel  Bard,  regarded  the  false  membrane  as  only  an  eschar ; 
the  subjacent  membrane  as  always  ulcerated. 

He,  however,  considered  the  false  membrane  as  formed  by 
the  thickened  mucus,  and  he  thought  the  mucous  membrane 
remained  intact.  Laboulbene,  who  has  studied  the  diphthe- 
ritic false  membranes  with  much  care,  assigns  to  them  two  prin- 
ciple elements : 

1,  An  amorphous  material,  a  sort  of  matrix,  sprinkled  with 
fine  molecular  granulations  which,  when  set  free,  become  agi- 
tated with  a  lively  molecular  movement. 

2.  The  fibrin  presents  the  appearance  of  slender  fibrillae, 
thin,  straight,  and  sometimes  parallel,  sometimes  intersecting  in 
every    direction ;  more    rarely  it  is   composed  of  very   small 


PATHOLOGICAL    ANATOMY.  57 

granules,  placed  in  juxtaposition  in  a  linear  series.  One  finds 
also  leucocytes,  granular  bodies,  numerous  fat  globules,  epi- 
thelial elements  in  various  degrees  of  development,  blood  glob- 
ules when  the  membranes  are  ecchymosed,  crystals  of  various 
forms,  very  rarely  vegetal  forms,  consisting  of  spores,  and  of 
mycelium,  as  well  as  vibriones  belonging  to  the  genera  .Bacte- 
rium and  Vibrio.  jg- 

The  locality  which  produces  the  false  membrane  impresses 
it  with  a  particular  character,  as  Laboulbene  recognized  from 
the  debris  of  epithelium  which  adhered  to  the  membrane. 

In  those  membranes  from  the  larynx  the  epithelium  is  cylin- 
drical, provided  with  cilia  at  the  large  extremity  of  the  cell; 
there  may  be,  moreover,  some  rare  cellules  from  nuclear  or 
pavement  epithelium.  Those  from  the  trachea,  and  large  bron- 
chi are  composed  especially  of  fibrin  and  ciliated  epithelial 
cells.  In  the  bronchi  of  smaller  calibre,  the  diphtheritic  con- 
cretions, recognizable  from  their  small  volume  and  from  the 
form  of  the  bronchi  upon  which  they  are  moulded,  present 
pavement  epithelium.  In  very  rare  cases  Laboulbene  observed 
pigmentary  granules. 

In  diphtheria  of  the  conjunctiva,  examined  in  the  beginning, 
the  fibrin  was  in  a  fibrillar  state ;  later  it  had  become  granular. 
In   diphtheria   of  the   genitals,   and   of  the    anus,    one    finds 
principally  fibrin  and  (pavement)  epithelium. 

Cutaneous  diphtheria  presents  an  amorphous  especially  fibri- 
nous stratum  mingled  with  pavement  cells  of  different  degrees 
of  development. 

Roger  and  Peter  describe  the  false  membranes  as  passing 
through  three  stages.  They  are  at  first  soft  and  diffluent,  then 
concrete  and,  finally,  pulpous. 

In  the  first  phase  they  are  formed  of  a  stroma  of  amorphous 
granular  matter,  in  the  midst  of  which  one  observes  a  series  of 
parallel  lines  which  are  nothing  but  fibrin  in  a  fibrillar  state. 

In  the  second  phase,  they  are  formed  of  the  same  stroma  of 
granular  fibrin,  in  the  thickness  of  which  exist  very  numerous 
free  nuclei,  rarely  round  cells,  epithelium  cells  and,  finally, 
straight  fibres,   sometimes   compacted  but   never  united    into 


58  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

bundles  of  connective  tissue.  In  no  case  does  one  discover 
any  vessels  nor  even  red  striae  as  indicating  the  formation 
(nisus)  of  vessels. 

In  the  third  phase,  the  period  of  detritus,  the  fibrillar  ap- 
pearance has  disappeared,  one  finds  no  longer  only  granular 
fibrin,  free  nuclei  and  leucocytes.  These  authors  say  this  is 
evidently  in  the  retrogressive  state. 

Jules  Simon  gives  a  similar  description. 

When  we  pass  to  the  examination  of  German  works,  we  en- 
counter from  the  first  a  confusion  of  words  which  contributes 
singularly  to  the  complication  of  the  question.  By  a  deplora- 
ble abuse  of  language,  applying  to  anatomico-pathological 
processes,  terms  which  serve  to  designate  diseases,  the  authors 
beyond  the  Rhine,  after  the  example  of  Virchow,  called  croup- 
al  inflammation  a  phlegmasia,  which,  without  touching  the 
structure  of  the  mucous  membrane,  deposits  upon  its  surface 
an  exudate,  a  false  membrane ;  and  diphtheritic  inflammation 
an  interstitial  phlegmasia,  characterised  by  a  sero-fibrinous  ex- 
udation, which  infiltrates  the  tissues  and  causes  their  mortifi- 
cation. Diverting  the  word  cronp  from  its  true  acceptation, 
which  is  that  of  an  acute,  suffocative  and  pseudo-membranous 
disease  of  the  larynx,  they  have  created  the  singular  terms, 
cronpal  pneumonia,  croupal  7iephritis,  etc.,  under  the  pretext 
that,  in  these  pathological  cases,  the  fibrinous  exudation  is 
formed  on  the  surface  of  the  pulmonary  alveoli,  urinary  tubuli, 
etc. 

Be  that  as  it  may,  the  German  work  may  be  summed  up 
under  two  opinions,  which  I  shall  now  present  in  detail : 

According  to  the  first,  set  forth  originally  by  Virchow,  and 
continued  by  Wagner,  Biihl  and  Rindfleisch,  the  false  mem- 
brane is  a  production  of  the  epithelium  of  the  mucous  mem- 
brane with  or  without  infiltration  of  the  mucous  corium. 

The  second  approaches  the  French  idea  of  exudation,  ex- 
cepting some  details.  The  false  membranes  are  formed  essen- 
tially of  emigrated  leucocytes  (Cohnheim)  and  a  fibrinous  sub- 
stance transuded  through  the  diseased  walls  of  the  vessels  of 
the  mucous  membrane  (Steudener,  Boldyrew,  Senator,  etc.). 


PATHOLOGICAL    ANATOMY.  59 

First  Theory. — The  work  which  presents  and  develops  this 
theory  the  best  is  that  of  E.  Wagner.  This  author  has  exam- 
ined the  false  membranes,  both  in  the  fresh  state  and  after 
hardening  in  alcohol.     The  following  are  his  conclusions : 

In  the  pharynx  arid  the  upper  part  of  the  larynx  the  mucous 
corium  presents  lesions  as  well  marked  as  those  of  the  epithe- 
lium. The  inflammation  there  is  always  diphtheritic,  that  is, 
interstitial. 

a.  Lesio7is  of  the  Epithelium. — The  epithelial  cells  undergo 
a  special  transformation,  which  he  calls  fibrinous ;  in  reality 
they  grow  by  an  infiltration  of  fibrin  into  their  interior.  Then 
are  developed,  especially  at  the  periphery,  small,  clear  spaces, 
round  or  oval,  which,  by  increasing,  displace  the  protoplasm. 
This  becomes  deformed,  elongated,  and  projects  ramifications 
which  soon  become  united  with  those  of  the  neighboring  cells, 
A  characteristic  network  is  thus  formed  in  which  one  can  no 
longer  recognize  a  nucleus. 

b.  Lesions  of  the  Corium. — At  first  the  mucous  membrane 
is  simply  congested,  later  it  becomes  the  seat  of  a  quite  active 
new  formation  of  young  cells  which  one  may  sometimes  fol- 
low even  into  the  sub-mucous  tissue. 

This  author  regards  these  two  processes  as  distinct,  and  as 
not  being  connected  necessarily  one  with  the  other.  At  one 
time  the  epithelial  lesion  predominates,  at  another  the  cellular 
neoplasia. 

In  the  liypoglottic  portions  of  the  larynx  and  in  the  trachea 
the  net  work  of  the  false  membrane  is  formed  of  thinner  threads 
and  of  more  compact  lamellae,  but  it  has,  as  in  the  pharynx, 
an  epithelial  origin.  It  is  constituted  by  the  union  [so?(dure) 
of  cylindrical  cells  which  have  undergone  fibrinous  transform- 
ation. But  the  young  cells  are  much  more  abundant  in  the 
meshes  of  the  network,  and  much  more  rare  in  the  corium. 

Biihl,  while  admitting,  as  does  Wagner,  the  fibrinous  trans- 
formation of  the  epithelium,  assigns  to  diphtheria  a  character- 
istic lesion  which  consists  in  the  infiltration  of  the  tissue  of 
the  mucous  membrane  with  cellular  or  nucleolar  bodies  {cyt'did 
Kbrper),  now  isolated,  now  united  to  the  number  of  from  two 


6o  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

to  six  upon  a  single  mass  of  protoplasm.  Quite  close  in  the 
superficial  layer  of  the  mucous  membrane,  they  are  more  scat- 
tered in  the  deeper  layers.  Their  formation  at  the  expense  of 
the  connective  tissue  cells  is  scarcely  demonstrated.  This 
new  formation  of  elements  of  the  mucous  membrane  was 
found  not  only  in  all  the  false  membranes  but  in  the  mucous 
membranes  which  were  not  covered  by  it.  From  this  fact, 
Biihl  deduced  an  argument  in  favor  of  the  general  nature  of 
the  disease.  In  a  case  of  diphtheritic  paralysis,  he  found  the 
nurilemma  thickened  at  a  point  corresponding  to  the  spinal 
ganglions ;  there  again,  the  new  formation  is  said  to  have  ef- 
fected its  work  and  produced  the  paralysis.  This  process 
would  recall,  to  a  certain  degree,  that  of  syphilitic  lesions. 

Rindfleisch  also  describes  separately,  croupal  (pseudo-mem- 
branous) inflammation  and  diphtheritic  (membranous)  inflam- 
mation, at  the  same  time  recognizing  that  there  is  only  a  dif- 
ference of  degree  and  not  of  nature  between  the  two  pro- 
cesses. 

The  false  membrane  is  composed  of  two  principal  elements : 

1.  A  special  transformation,  called  vitreous,  of  the  epithe- 
lium. 

2.  A  fibrinoid  exudate  coming  from  the  vessels.  One  sees 
that  this  theoiy  lends  support,  on  one  hand,  to  that  of  Wag- 
ner, and  on  the  other  to  that  which  the  most  recent  German 
works  have  set  forth. 

According  to  Rindfleisch,  croupal  inflammation  differs  from 
catarrhal  inflammation  of  the  mucous  membrane  only  in  the 
specific  nature  of  the  product — a  body  analogous  to  fibrin 
becoming  clear  by  the  action  of  acetic  acid.  In  the  pharynx 
the  greater  part  of  the  false  membrane  is  formed  of  cells 
which  have  undergone  the  vitreous  transformation.  The  pro- 
cess develops  in  islets  and  recovers  without  producing  any 
cicatrix  of  the  mucous  membrane.  In  the  larj'nx  there  can 
be  no  doubt  of  the  presence  of  fibrin;  the  false  membrane 
is  formed  of  stratified  layers  of  young  cells  alternating  with 
layers  of  fibrin.  The  submucous  tissue  is  more  or  less  infil- 
trated with  young  cells.     In  diphtheritic  inflammation  there 


PATHOLOGICAL    ANATOMY.  6l 

arises  in  the  thickness  of  the  corium  an  exudation  so  intense 
that  it  entails  the  necrosis  of  the  tissue,  hence  the  production 
of  eschars  which  detach  themselves  and  leave  after  them  cica- 
trices. 

Second  Theory. — By  one  of  those  reversions  so  common  in 
histology,  the  most  recent  researches  concur  in  returning  to 
honor  the  works  of  ancient  observers,  which  were  for  a  mo- 
ment contested,  by  supporting  them  with  the  influence  of  the 
modern  means  of  investigation.  Boldyrew,  Steudener  and 
Senator  established  clearly  that  in  the  genesis  of  the  false 
membrane,  vascular  exudation  is  the  principal  fact,  and  that 
the  epithelial  alteration  presents  an  importance  entirely  second- 
ary. Boldyrew  verified  in  the  false  membrane  the  presence  of 
the  following  elements  : 

1.  Fibrin,  deposited  in  parallel  layers  which  one  may  some- 
times succeed  in  separating  like  the  concentric  layers  of  an 
onion.  The  fibrinous  network  is  very  rich.  One  finds  accum- 
ulated mucus  in  certain  parts  of  the  false  membrane,  particu- 
larly in  proximity  to  the  excretory  canals  of  the  glans  of  the 
mucous  membrane. 

2.  Pus  in  great  abundance  in  the  thickness  of  the  false  mem- 
brane, especially  at  first.  The  epithelium  has  totally  disap- 
peared, and  the  mucous  membrane  is  infiltrated  with  leuco- 
cytes. One  finds  neither  congestion  in  the  capillaries  nor 
haemorrhage.  Steudener  in  examining  the  false  membrane  of 
the  larynx  and  of  the  trachea  gave  nearly  the  same  descrip- 
tion. He  insisted  upon  the  fact  of  the  total  absence  of  the 
epithelium  and  upon  the  infiltration  of  the  corium  and  often 
even  of  the  submucous  tissue  with  round  cells.  He  admits 
with  Cohnheim  an  alteration  of  the  walls* of  the  vessels  (po- 
rosity of  Rindfleish)  which  permits  the  emigration  of  the  white 
globules  and  the  exudation  of  fibrin.  To  the  assertions  of 
Wagner  he  offers  the  following  objections: 

1.  The  threads  of  the  network  of  the  tracheal  false  mem- 
brane are  too  thick  for  it  to  be  possible  for  them  to  be  formed 
at  the  expense  of  the  little  pre-existent  cylindrical  cells. 

2.  The  number  of  the  cells  is  too  considerable  to  arise  from 
the  epithelium. 


62  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

3.  One  cannot  explain  by  his  theory  the  rapid  formation  of 
new  false  membranes  after  the  falling  off  of  the  old  one,  since 
there  is  no  longer  any  trace  of  epithelium  there. 

4.  He  never  observed,  neither  in  the  larynx  nor  in  the  trachea, 
the  fibrinous  transformation  described  by  Wagner. 

5.  The  lesions  observed  in  the  inflamed  serous  membranes 
by  Cohnheim  resemble  so  closely  those  met  with  in  croup  that 
they  may  be   inte  preted  in  the   same  manner. 

These  very  weighty  objections,  added  to  those  researches 
which  we  have  just  analysed  and  those  which  remain  for  us  to 
present,  give  to  the  theory  of  Wagner  a  blow  from  which  it 
will  with  difficulty  recover. 

Senator,  in  a  remarkable  work,  made  a  decided  step  toward 
the  ideas  of  Brettoneau.  In  a  more  philosophical  spirit,  more 
of  a  generalizer  than  his  predecessors,  he  no  longer  held  to 
the  single  anatomical  nature  which  had  inspired  in  them  the 
separation  of  the  croupal  and  the  diphtheritic  affections.  He 
preserved,  it  is  true,  these  denominations,  but  he  applied  them 
to  anatomical  varieties  which  enter  into  a  common  whole,  and 
this  he  called  diphtheria  after  the  example  of  Trousseau. 

He  described  four  anatomical  forms  of  diphtheria : 

1.  Catarrhal  form.  One  frequently  meets  during  an  epi- 
demic cases  of  simple  catarrhs  of  the  air  passages,  which  may 
degenerate  into  true  diphtheria,  of  which  they  are  evidently 
the  first  stage  or  a  slight  attack.  The  author  thus  gives  an 
anatomical  sanction  to  the  purely  French  idea  of  diphtJicria 
without  diphtheria,  that  is,  diphtheria  without  the  false  mem- 
brane, of  which  I  shall  show  later  the  reality. 

2.  The  croupal  form  of  which  the  type  is  found  in  the  pseu- 
do-membranous inflammation  of  the  larynx  and  trachea.  The 
fibrin  stratified  in  lamellae  and  the  leucocytes  chiefly  consti- 
tute the  false  membrane ;  underneath,  the  mucous  membrane 
is  strongly  hperaemic  and  infiltrated  with  young  cells.  This 
anatomical  form  is  never  met  with  pure  in  the  pharynx.  But, 
says  Senator,  no  person  will  deny  to-day  that  true  anatomical 
croup  maybe  developed  under  the  influence  of  diphtheritic  con- 
tagion, that  is  to  say,  there  is  a  diphtheritic  croup  coincident 
with  diphtheritic  inflammation  of  the  pharynx. 


PATHOLOGICAL    ANATOMY.  6$ 

3.  The  pseudo-croupal  form  which  is  characterized  by  grey 
or  milky  membranes  scattered  in  patches  or  bands  upon  the 
mucous  membranes  of  the  soft  palate,  and  the  tonsils,  and 
more  rarely  upon  the  buccal  mucous  membrane.  They  may 
be  easily  separated,  and  underneath  one  finds  the  mucous 
membranes  perfectly  healthy.  They  are  composed  essentially 
of  epithelium  easily  recognizable  on  the  spot,  and  of  low  forms 
of  fungi  (leptothrix,  etc.),  which  are  probably  the  cause  of  the 
alteration  and  putrefaction  of  the  epithelium,  as  in  aphthaii^ 
but  with  this  difference:  there  is,  in  this  later  case  another  kind 
of  fungi.  There  is  neither  pus  nor  fibrin.  This  form,  often 
quite  benign  and  purely  local,  may  appear  during  an  epidemic 
and  be  followed  by  true  diphtheria. 

This  description  seems  to  resemble  very  closely  the  form 
called  catarrh  of  the  author ;  and  it  seems  that  he  might  have 
united  them  with  advantage. 

4.  The  diphtheritic  for»i  properly  so-called  is  that  in  which 
the  process  is  gangrenous  and  not  pellicular.  The  description 
which  Senator  gives  of  it  accords  with  that  of  Rindfleisch. 
From  an  anatomical  point  of  view  his  work  presents  nothing 
especially  new ;  but  on  the  part  of  nosography  a  grand  advan- 
tage is  realized  over  other  German  authors  by  recognizing  that 
the  different  anatomical  forms  all  arise  from  the  same  cause, 
namely,  diphtheritic  contagion.  How  different  this  from  Wag- 
ner, who,  fashioning  the  pathology  to  suit  his  ideas  of  the  anat- 
omy maintains  that  the  same  patient  may  have  at  the  same 
time,  but  by  simple  coincidence,  two  different  diseases;  one  a 
diphtheria  of  the  pharynx  and  of  the  larynx  above  the  glottis, 
and  later  a  croup  of  the  hypoglottic  portion  of  the  larynx  and 
of  the  trachea. 

Niemeyer,  while  preserving  the  distinction  between  the 
croupal  and  the  diphtheritic  processes,  and  recognizing  simple 
croup,  differs  formally  from  physicians  who  confound  this  sim- 
ple croup  with  croupal  laryngitis  dependent  upon  diptheritic 
infection.  He  says,  "  I  cannot  sha^e  in  this  view.  The  divi- 
sion of  diseases  according  to  the  anatomico-pathological  mod- 
ifications which  they  entail  in  their  train  is  but  a  last  shift. 


64  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

Whenever  it  is  possible  to  demonstrate,  as  occurs  in  primary- 
croup  and  diphtheritic  croup,  that  two  disturbances  of  nutri- 
tion anatomically  alike  have  an  essentially  different  origin,  we 
are  no  longer  allowed  to  confound  one  with  the  other.  *  *  *" 
Diphtheria  is  seen,  finally,  in  its  true  light  by  Warimann  and 
Hagner,  who  consider  it  as  one  process  susceptible  of  taking 
on  distinct  anatomical  forms  according  to  the  organ  on  which 
it  is  localized.  The  works  of  the  French  school  experience, 
during  these  latter  years,  the  German  influence.  The  princi- 
pal are  those  of  Lorain  and  Lepine,  Cornil  and  Ranvier,  ]\Iath- 
ias  Duval,  and  RebouUet.  Let  us  note,  however,  a  memoir  of 
Homolle,  in  which  the  author  demonstrates  that  the  exudate 
is  formed  of  a  coagulable  liquid  in  which  are  imprisoned  the 
young  cells  deposited  in  large  quantity  on  the  surface  of  the 
mucous  membrane. 

The   Parasitic  Element. 

The  fibrin,  the  leucocytes  and  the  epithelial  transformations 
are  not  the  only  products  which  are  met  with  in  the  false  mem- 
brane of  diphtheria.  Several  observers  have  also  discovered 
in  it  fungi  or  inferior  algae.  Laboulbene  has  mentioned  vibri- 
ones.  I  have  already  reported  his  description.  Other  authors 
have  gone  still  farther;  they  have  been  disposed  to  make  these 
organisms  the  specific  lesion  of  diphtheria.  Hallier  found  the 
spores  of  an  undescribed  fungus  which  he  called  the  diplospo- 
runn  fuscmn.  Letzerich,  who  has  made  some  thorough  inves- 
tigations and  formed  from  them  an  entire  theory,  admits,  to  the 
exclusion  of  all  other  fungi,  the  zygodesmiis  fuscus  which  he 
has  followed  as  far  as  into  the  lymphatic  ganglions,  the  mus- 
cles, and  into  the  kidneys  where  it  formed  a  true  layer  {^pilz- 
ladeii).  Penetrating  into  the  mucous  net-work  of  Malpighiand 
into  the  connective  tissue,  the  fungus  provoked  the  formation 
of  patches  of  exudate ;  at  the  same  time  it  corrodes  the  walls  of 
the  neighboring  blood  vessels  and  lymphatics,  and  penetrates 
into  their  cavity,  where  it  forms  parasitic  emboli.  Once  entered 
into  the  circulatory  system,  the  spores  have  the  faculty  of  es- 
caping thence  by  a  kind  of  transudation  and  extending  into  the 


PATHOLOGICAL    ANATOMY.  65 

surrounding  tissues,  where  they  constitute  new  foci.  In  this  way- 
are  produced  the  lesions  of  the  lungs,  the  heart,  the  kidneys 
the  nerves,  the  muscles,  etc. 

The  theory  is  complete,  as  we  see,  and  plausible ;  it  has  led  as- 
tray several  German  authors,  Biihl  and  Neumann  among  others. 
B.  Napier  has  found  these  fungi,  but  also  in  children  perfectly 
healthy.  Many  other  pathological  anatomists  have  sought 
without  finding  the  fungus  of  Letzerich.  Among  them  we  may 
mention  Max  Jaffe.  This  author  has  observed  accidentally  in 
diphtheretic  false  membranes  low  vegetable  forms  :  oidium  albi- 
cans and  leptothrix  biiccalis ;  but  he  accords  to  them  no  specific 
significance. 

Rud,  Demme,  of  Berne,  holds  the  same  opinion.  Classen,  of 
Rostock,  has  never  met  with  the  zygodesmus  fuscus,  but  he  de- 
scribes little,  round,  brilliant,  mobile  bodies  analogous  to  those 
observed  by  Hallier  in  variola  and  in  other  diseases.  He  sup- 
poses that  these  organisms  exert  a  special  action  upon  the  epi- 
thelium, which  induces  upon  the  latter  the  alterations  such  as 
Wagner  insists  upon. 

Hueter  and  Tommasi  have  observed,  in  the  blood  of  persons 
attacke  1  with  diphtheria,  small  round,  shining,  very  mobile 
points,  which  they  have  also  seen  in  the  false  membranes  and  in 
the  diphtheritic  inflammations  produced  experimentally. 

But  Bittleheim  has  demonstrated  that  these  points  are  not 
specific,  since  they  are  found  also  in  the  blood  of  persons  in 
good  health. 

In  the  view  of  Nassiloff,  Oertel,  Classen  and  Eberth,  the  spe- 
cific parasite  is  a  micrococcus  of  which  they  have  recognized 
large  quantities  in  the  false  membranes,  in  the  interior  of  the 
cells  of  the  mucous  membrane,  in  the  neigboring  vessels  and 
lymphatic  ganglions  and  in  the  viscera.  They  have  found  it 
in  the  cases  of  inoculated  diphtheria  (diphtheritic  inoculation) 
and  Oertel  has  made  the  remark  that  it  always  fails  in  experi- 
mental croup  caused  by  ordinary  caustic  substances.  These 
authors  therefore  conclude  that  the  false  membrane  is,  at  the 
beginning,  a  local  affection  caused  by  the  presence  of  the  mi- 
crococcus and  that  the  general  infection  is  produced  by  tiie 
penetration  of  the  parasite  into  the  organism. 


66  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

Senator  refutes  peremptorily  these  conclusions.  He  has 
never  observed  the  fungus  described  by  Letzerich.  He  has 
constantly  found  in  the  false  membranes  of  the  throat  (i.)  small 
round  bodies  with  sharp  outlines,  from  one  (i)  to  two  , a  (2) 
(1/25000  in.)  in  diameter,  resisting  the  action  of  ether  and  of 
caustic  potash,  sometimes  stationary,  sometimes  movable,  which 
he  regards  as  spores  of  lepothrix  buccalis  or  of  monas  cre- 
pusculum\  (2.)  vibriones;  (3.)  leptothrix  buccalis.  But  these 
round  bodies  are  obsers^ed  in  the  aphthous,  ulcerous  and  mer- 
curial inflammations  of  the  mouth.  Senator  was  able  in  these 
cases  to  obtain  the  same  figures  as  Oertel  had,  by  leaving  a 
small  piece  of  meat  for  some  time  in  the  mouth  of  the  patient. 
He  saw  distinctly  the  spores  in  the  muscular  tissue.  The  pre- 
ferred seat  of  these  organisms  is  found  in  the  false  m.embranes 
of  the  throat ;  they  are  wanting  or  are  very  rare  in  those  which 
come  from  the  respiratory  passages.  These  microphytes  are, 
therefore,  not  necessary  to  the  development  of  the  false  mem- 
branes ;  they  are  carried  by  the  air,  deposited  upon  the  first  ex- 
udates which  they  meet  and  are  there  developed  as  they  are 
usually  upon  organic  matters  exposed  to  warm  moist  air  and 
consequently  exposed  to  putrefaction. 

It  is  in  fact  upon  the  old  false  membranes  already  more  or 
less  altered,  that  they  are  observed.  We  may  add,  that  the 
numerous  experiments  to  which  persons  have  applied  them- 
selves with  the  object  of  inoculating  these  vegetable  growths 
have  given  only  negative  results.  From  what  precedes  it  fol- 
lows that  the  spores  set  forth  as  the  morbific  germs  of  diph- 
theria do  not  merit  such  a  title,  and  that  new  observations  and 
solid  proofs  are  needed  to  establish  diphtheria  as  a  parasitic 
disease. 

Conclusions. — What  must  we  conclude  from  the  preceding 
views  ?  The  whole  question  reduces  itself  to  two  points  :  Is 
the  false  membrane  a  fibrinous  exudate  ?  Or  is  it,  on  the  con- 
trary, a  product  of  epithelial  transformation  ? 

The  second  opinion  admitted  in  whole  by  Wagner  and  Buhl, 
and  in  part  by  Rindfleisch,  is  combatted  by  Boldyrew,  Steu- 
dener  and  Senator,  who  return  to  the  theory  of  Bretonneau  by 


PATHOLOGICAL    ANATOMY.  6/ 

perfecting  it  and  bringing  it  up  to  a  level  with  modern  science. 

The  arguments  with  which  the  latter  authors  combat  those  of 
their  opponents  have  been  presented  in  detail.  There  is  a 
point  on  which  all  the  world  is  now  agreed :  that  is,  the  exud- 
ative nature  of  the  false  membrane  in  the  sub-glottic  portions 
of  the  larynx  and  in  the  remainder  of  the  respiratory  passages. 
On  this  subject  modern  observers  hold  common  ground  with 
the  ancients. 

When  we  come  to  the  pharyngeal  false  membrane  diverg- 
ences arise,  but  more  apparent  than  real. 

According  to  Senator,  the  necrotic  process  is  the  almost 
constant  rule ;  on  the  other  hand,  when  he  describes  the  laryn- 
geal false  membrane  he  is  careful  to  tell  us  that  this  anatomical 
form  is  never  found  pure  in  the  pharynx.  Upon  this  latter 
point  he  is  entirely  correct,  the  more  so  as  this  proposition 
rectifies  that  in  which  the  first  was  too  absolute. 

Certainly  the  gangrenous  (necrotic)  process  is  observed  in 
the  pharynx,  and  much  more  frequently  than  the  school  of 
Bretonneau  thought ;  but  we  fall  into  error  by  supposing  that 
all  the  diphtheritic  false  membranes  of  the  pharynx  are  eschars. 
It  is  evident  that  the  authors  who  formulated  this  latter  opinion 
made  their  examinations  in  only  one  cf  the  forms  of  diphtheria, 
the  grave  form  which  resembles  gangrene  or  is  accompanied 
with  it.  But  the  product  of  diphtheria  presents  itself  under  the 
most  varied  forms.  While  there  are  some  false  membranes 
which  are  thick,  firm,  adherent,  grey  or  brown,  others,  on  the 
contrary,  are  thin,  transparent,  white,  slightly  adherent,  and 
become  detached  in  a  very  short  time.  It  cannot  be  a  ques- 
tion, in  these  latter  cases,  of  eschars  and  of  the  gangrenous 
process.  [The  question  is  so  strongly  in  the  negative  that  there 
is  no  ground  for  disagreement.] 

This  difference  did  not  escape  Rindfleisch,  who,  though  a 
partisan  of  the  epithelial  transformation,  described  the  croupal 
inflammation  of  the  pharynx.  Niemeyer  did  the  same  thing, 
but  he  considered  croup  of  the  pharynx  as  foreign  to  the 
diphtheritic  infection. 

Disregarding  the  interpretation  as   insignificant,  let  us  only 


68  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

establish  the  anatomical  fact — a  superficial  fibrinous  exudation 
may  be  produced  on  the  surface  of  the  pharynx.  Therefore, 
while  affirming  that  the  false  membranes  of  the  pharynx  and 
of  the  larynx  are  of  the  same  nature  and  proceed  from  the 
same  cause,  I  am  prepared  to  recognize  that  these  morbid 
products  offer  certain  differences  of  aspect  To  present  these 
diverse  characteristics  in  their  true  light,  to  exhibit  their  real 
nature:  this   is  the  important  point  in  the  question. 

It  is  not  to  different  processes  that  these  pellicular  varieties 
owe  their  existence.  The  morbid  action  is  the  same,  only  its 
effects  vary  with  the  intensity  of  this  same  action  and  with  the 
structure  of  the  mucous  membrane  on  which  it  is  developed. 
That  is  a  principle  of  general  pathology  applicable  to  diph- 
theria as  well  as  to  other  diseases.  The  question  thus  brought 
back  to  its  true  terms,  let  us  see  the  influence  that  these  two 
factors  exercise  upon  their  products.  The  inflamed  mucous 
membrane  presents  among  others  the  well-known  alterations  of 
the  vascular  walls,  lesions  which,  according  to  the  generally  re- 
ceived opinions  of  Cohnheim,  permit  the  emigration  of  leuco- 
cytes and  the  exudation  of  fibrin.  That  settled,  we  easily  see 
how  the  product  may  vary  under  the  influence  of  the  intensity 
of  the  cause. 

When  the  inflammation  is  slight  an  exudation  is  formed  on 
the  surface  of  the  mucous^membrane  which  is  itself  infiltrated 
with  young  cells.  But  the  lesion  is  superficial,  slightly  intense 
and  recovers  without  cicatrix.  At  a  higher  degree  the  exuda- 
tion is  more  profound,  and  the  vitality  of  the  mucous  membrane 
suffers,  and  a  slight  loss  of  substance  follows  the  elimination. 
Finally,  in  the  grave  cases  which  correspond  to  what  the  Ger- 
mans call  the  diphtheritic  form  the  inflammatory  impetus  is 
energetic,  the  exudation  of  fibrin  and  of  young  cells  is  pro- 
found and  dense,  and  it  chokes  the  circulation  in  the  invaded 
parts.  These  latter  mortify,  assume  an  ashy  grey  color  or 
brown,  and  from  that  time  on  follow  the  course  of  eschars. 

The  structure  of  the  mucous  membrane  leaves,  no  more  than 
the  first,  any  special  character  upon  the  product  of  its  inflam- 
mation.    In  the  pharynx  and  in   the   hyper-glottic  portion    of 


PATHOLOGICAL    ANATOMY.  69 

the  larynx,  the  epithelium  is  thick  and  composed  of  pavement 
cells  ;  it  adheres  intimately  to  the  mucous  corium.  This  an- 
atomical condition  favors  the  profound  infiltration  of  the  tis- 
sues ;  it  explains  why  the  pharyngeal  false  membrane,  while 
remaining  superficial  and  slightly  adherent  in  the  cases  in 
which  the  process  is  moderate,  becomes  thick  and  tenacious 
under  opposite  circumstances,  and  how,  without  having  the 
gangrenous  appearance,  it  may  leave,  after  its  separation,  a 
loss  of  substance  in  the  mucous  membrane. 

In  the  hypo-glottic  portion  of  the  larynx,  on  the  contrary, 
as  well  as  in  the  remainder  of  the  air  passages,  the  epithelium 
is  composed  of  cylindrical  cells  much  thinner;  but  what 
changes  principally  the  anatomical  conditions,  is  the,  existence 
of  the  basement  vicvibrane  of  Bowman,  an  amorphous  layer 
which  separates  the  epithelium  from  the  corium  and  forms  a 
difficult  barrier  to  cross.  By  studying  this  disposition,  we 
explain  the  generally  superficial  character  and  feeble  adher- 
ence of  the  false  membranes  which  are  produced  at  these 
points. 

Chemical  Characters. 

From  all  time  fibrin  has  been  considered  as  the  funda- 
mental element  of  the  false  membrane.  The  school  of  Vir- 
chow  itself,  while  no  longer  according  to  this  substance  but  a 
secondary  place,  has  not  been  able  to  exclude  it  completely, 
and  admits  its  existepce  in  the  false  membrane,  or  at  least,  the 
presence  of  an  analogous  material,  a  fibrinoid  substance. 

The  most  recent  works  published  in  Germany  (Steudener 
and  Senator)  have  assigned  to  fibrin  its  predominant  part ; 
we  are  able  to  establish  by  all  observers  that  the  chemical 
composition  of  the  diphtheritic  product  is  represented  by  the 
following  elements:  i.  Fibrin;  2.  An  amorphous  material; 
3.  Fatty  matters  in  considerable  quantity  ;  4.   Mucin. 

According  to  Robin,  the  false  membrane  is  formed  by  an 
exudation  of  plasmine  which  separates  into  two  parts,  a  liquid 
part  which  escapes  (flows  off),  and  another  part  which,  coag- 
ulating in  the  form  of  fibrin,  gives  rise  to  the  membranes. 


yO  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

But  it  is  not  sufficient  to  know  the  chemical  composition  of 
a  body,  it  is  important  also  to  know  how  it  behaves  in  the 
presence  of  different  reagents.  This  part  of  the  history  of 
false  membranes  has  been  considered  as  very  important,  thanks 
to  that  opinion  which  has  prevailed  for  a  long  time,  namely : 
that  the  false  membranes  being  the  disease  itself  and  not  its 
product,  it  is  important  above  all  to  remove  a  pathological 
element  the  presence  of  which  would  favor  the  entrance  of 
morbid  principles  into  the  economy.  It  is  with  the  hope  of 
discovering  an  agent  capable  of  rapidly  destroying  the  diph- 
theritic exudate  that  the  latter  has  been  brought  into  contact 
with  a  large  number  of  reagents,  of  which  some  give  theoret- 
ically hope  of  the  more  or  less  easy  solution  of  the  fibrinous 
exudate.  In  a  former  work  I  have  examined  this  question 
principally  from  a  therapeutical  point  of  view;  I  will  now 
repeat  it  in  its  ensemble. 

Water  has  upon  the  false  membranes  only  an  insignificant 
action;  at  the  end  of  three  or  four  hours  of  immersion,  the 
diphtheritic  pellicle  is  separated  into  parts  (desagrege)  but 
without  there  being  any  solution. 

Alcohol,  by  dissolving  the  fatty  exudate,  hardens  and  shriv- 
els it. 

Glycerine  swells  it  and  makes  it  transparent. 

Among  the  metalloids  iodine  and  bromine  have  a  certain 
action. 

Iodine  employed  in  the  form  of  tincture  colors  the  false 
membranes  yellow  and  hardens  them. 

A  zvatery  solution  of  bromine  hardens  them  and  renders  them 
friable  and  destroys  their  aggregation. 

The  acids  nearly  all  produce  a  decided  action  upon  the 
pseudo-membranes. 

Mineral  Acids. — Sulphuric  acid  diluted  with  water  shrivels, 
darkens,  softens  and  dissolves  them. 

Nitric  Acid  colors  yellow  and  separates  by  feebly  dissolving 
them. 

Hydrochloric  acid  concentrated  softens  and  swells  the  false 
membrane. 

Chromic  acid  hardens  it  and  turns  it  yellow. 


PATHOLOGICAL    ANATOMY,  7I 

Organic  Acids. — Tannic  acid  shrivels  and  slightly  contracts 
it. 

Acetic  acid  acts  in  the   same   manner  as  hydrochloric   acid, 
but  more  completely ;  it  swells  and  softens  the  false  membrane. 
Citric  acid  attenuates  without  dissolving  it  entirely ;  a  thin 
net-work  remains  in  the  liquid. 

Lactic  acid  studied  by  Adrian  and  Bricheteau  has,  ac- 
cording to  these  authors,  a  more  decided  action.  Two  drops 
of  this  acid  diluted  in  five  (5)  grammes  (seventy-five  minims) 
of  water  in  a  few  seconds  reduce  the  false  membranes  to  a  state 
of  translucent  net-work ;  at  the  end  of  ten  minutes  there  re- 
main in  the  liquid  only  a  few  fragments,  scarcely  perceptible, 
of  a  gelatiniform  substance  like  scum  or  dregs.  The  addition 
of  a  few  drops  of  the  acid  removes  every  trace  of  solid  sub- 
stance, but  there  always  remains  a  slight  cloud.  I  have  re- 
peated these  experiments  with  the  solution  recommended  by 
these  authors,  viz.,  lactic  acid  five  grammes,  to  water  one 
hundred  grammes.  The  thinning  of  the  false  membrane  was 
effected  very  rapidly,  but  the  fibrous  net-work  remained,  though 
I  brought,  by  degrees,  the  quantity  of  lactic  acid  to  fifteen 
grammes  to  the  same  quantity  of  water.  I  operated  upon 
false  membranes  of  three-fifths  of  an  inch  (d'un  centimetre  et 
demi)  in  width.  This  disagreement  has,  however,  but  a  sec- 
ondary importance.  The  principal  fact  is  admitted ;  lactic 
acid  reduces  a  false  membrane  in  a  few  minutes  to  a  net-work 
so  thin  that  it  becomes  insignificant  so  far  as  a  local  lesion  is 
concerned. 

Alkalies. — The  solutions  of  potassa,  of  soda  and  of  a'}nfnonia 
act  upon  the  diphtheritic  products  by  causing  them  to  swell 
and  softening  them. 

Lime-zvater,  above  all  the  preceding  bodies,  is  the  best,  and 
acts  the  most  rapidly  in  dissolving  the  false  membranes.  Its 
solvent  power  was  signalized  by  Kiichenmeister;  I  have  ob- 
served it  very  many  times,  and  have  proved  it  by  experiment. 
Take  a  false  membrane  half  an  inch  or  more  in  size,  throw  it 
into  a  graduated  tube  containing  six  cubic  centimetres  of 
lime-water,  and  the  water  will  immediately  be  seen  to  become 


72  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

clouded  and  the  exudate  to  become  rapidly  thin.  At  the  end 
of  ten  minutes  there  remains  only  a  transparent  net-work 
which  itself  disappears  in  about  half  an  hour,  possibly  less. 
The  liquid  becomes  cloudy,  but  it  always  remains  sufficiently 
transparent  easily  to  show  what  remains  of  the  false  membrane. 
By  the  next  day  the  liquid  has  again  become  clear,  and  a 
white  sediment  is  deposited  at  the  bottom  of  the  tube.  This 
reaction,  like  all  those  which  have  for  their  object  the  false 
membranes,  do  not  always  act  with  the  same  rapidity.  Some- 
times five  minutes  suffice  for  the  complete  solution  ;  but  it 
may  occur  that  the  fibrillary  net-work  will  persist  and  remain 
insoluble  ;  and  finally,  in  other  cases,  the  false  membrane  re- 
mains refractory. 

The  explanation  of  this  variety  of  action  is  found  in  the 
differences  in  structure  of  the  diphtheritic  product.  One  which 
is  furnished  by  a  gangrenous  angina  and  which  contains 
within  the  fibrin  fragments  of  mortified  tissues  remains  in 
large  part  insoluble,  or  at  least  but  little  sensible  to  the  in- 
fluence of  the  reagent.  Exudates,  themselves  purely  fibrinous, 
do  not  behave  entirely  in  the  same  manner.  They  are  at- 
tacked the  more  easily  in  proportion  as  they  are  thinner  and 
more  recent.  When  they  are  old,  thick,  compact,  and,  more- 
over, composed  of  stratified  layers,  they  resist  obstinately. 
We  will  yet  notice  a  substance  which  possesses  a  great  analogy 
to  lime-water  and  of  which  the  properties  are  similar,  I  mean 
the  saccharate  of  lime,  as  it  is  obtained  by  saturating  simple 
syrup  with  slaked  lime.  I  have  already  called  attention  to  its 
affinities  for  the  false   membrane,  [In  a  former  work.] 

Neiiti'al  Salts.  The  chlorate  of  potassium  studied  by  Isam- 
bert  possesses  incontestibly  a  solvent  action,  but  mild. 

The  chlorate  of  sodium  pointed  out  by  Barthez  exercises  a 
solvent  power  twice  as  strong  as  its  congener. 

Alkaline  Salts. — The  bicarbonate  of  soda  in  solution  acts  but 
feebly.     Applied  in  powder  its  action  is  more  manifest. 

The  bromide  of  potassium,  to  which  Ozanam  attaches  great 
importance,  gives  about  the  same  results  as  the  preceding  salts; 
but  these  results  are  obtained  still  more  slowly. 


PATHOLOGICAL    ANATOMY.  73 

The  hypobromite  of  soda  is,  of  all  the  bromine  compounds, 
the  most  active  in  reference  to  its  influence  upon  the  false 
membranes.  After  having  studied  the  action  of  a  solution  of 
bromine  and  that  of  the  solution  of  bromide  of  potassium,  I 
was  led  by  accident  to  try  the  hypobromite  of  soda,  which  I 
employed  with  a  very  different  object.  I  made  examinations 
of  the  variations  of  urea  in  specimens  of  urine  by  the  method 
of  Regnard,  a  method  which  consists  in  treating  urine  with  a 
solution  of  hypobromite  of  soda,  a  substance  which  is  ob- 
tained by  mixing  sixty  (60)  cubic  centimetres  of  lye  or  so- 
lution of  caustic  soda  with  seven  cubic  centimetres  of  bro- 
mine, to  which  is  added  one  hundred  and  forty  cubic  centi- 
metres of  distilled  water.  Finding  that  I  had  a  compound  of 
bromine  not  yet  tried  in  its  relations  to  the  product  of  diph- 
theria, I  thought  I  would  make  a  trial  of  it.  I  witnessed  a 
very  powerful  solvent  action,  equal  to  that  of  lime-water. 

The  chloride  of  sodium  is  indifferent  to  the  plastic  products. 

Metallic  Salts. — Nitrate  of  silver  does  not  dissolve  the  false 
membrane,  it  contracts  and  condenses  it. 

The  perchloride  of  iron  has  no  direct  action  upon  it.  Aubrun 
has  shown  that  this  salt,  in  the  presence  of  organic  matters, 
is  decomposed  into  hydrochloric  acid,  which  is  set  free,  and 
into  oxyde  of  iron,  which  is  precipitated  and  can  be  removed 
by  scraping. 

The  mcrcmial  salts,  calomel,  red  precipitate,  einabar,  etc.,  pro- 
duce in  a  state  of  powder  a  slightly  solvent  action.  Before 
closing  this  list  of  reagents,  alieady  long,  I  should  mention 
alum,  a  substance  the  action  of  which  is  analogous  to  tannin. 

Evolution. — Pathological  Physiology. 

The  mucous  membrane  in  the  formation  of  the  diphtheritic 
false  membrane  becomes  the  seat  of  an  inflammatory  action 
which  is  peculiar  in  its  origin  and  course,  yet  presents  all  the 
known  characteristics  of  phlegmasia  of  the  mucous  mem- 
branes. The  capital  point  of  this  elaboration  is  the  transuda- 
tion through  the  vessels  of  a  fibrinoid  substance  to  which  is 
added  quite  a  considerable  number  of  emigrated  leucocytes. 
(Cohnheim.) 


74  DIPHTHERIA,    CROUP    AND    TRACAEOTOMY. 

At  first  the  false  membrane  is  thin,  soft  and  semi-transparent. 
The  German  school  has  maintained  and  still  maintains  that 
this  kind  of  false  membrane  is  peculiar  to  the  respiratory- 
passages  and  is  never,  or  almost  never,  observed  in  the  throat, 
the  necrotic  process  being  limited  to  the  latter.  I  have  given 
the  reasons  which  convince  me  of  the  inaccuracy  of  this  view. 

At  the  end  of  a  very  short  time,  a  few  hours  generally,  the 
exudation  continuing,  the  false  membrane  becomes  thicker, 
harder  and  reaches  its  full  development.  At  the  same  time  it 
increases  in  surface.  It  is  rare  that  it  assumes  from  the  first 
its  full  dimensions ;  it  makes  its  appearance  as  a  round  patch, 
often  quite  circumscribed,  even  punctiform,  which  develops 
eccentrically.  This  mode  of  extension  is  sometimes  quite  re- 
markable ;  there  exists  at  the  outset  but  one  or  more  little 
points  which  have  the  greatest  analogy  to  herpetic  vesicles  or 
to  the  concretions  of  the  tonsils  ;  they  enlarge,  unite  if  there 
be  a  certain  number  of  them,  and  end  by  forming  one  or  more 
diphtheritic  membranes  well  marked,  such  as  we  meet  in  grave 
angina  and  in  croup.  I  have  often  seen  infectious  angina,  fol- 
lowed or  not  by  croup,  begin  in  this  manner.  Pseudo-mem- 
braneous inflammation,  when  it  begins  on  a  single  point  or  on 
several  at  a  time,  extends  by  contiguity,  and  quite  frequently 
assumes  a  remarkable  tendency  to  propagate  itself  from  above 
downwards. 

Bretonneau,  who  had  apprehended  this  peculiarity,  admitted 
as  an  explanation  that  the  parts  first  affected  furnished  an 
acrid,  virulent,  epispastic  liquid  which,  escaping  towards  the 
dependent  parts,  irritated  the  latter  and  communicated  to  them 
pseudo-membraneous  inflammation.  This  hypothesis  could 
not  stand  before  a  careful  examination  of  the  facts.  The 
existence  of  this  acrid  liquid  is  more  than  doubtful.  More- 
over, the  descending  progress  of  the  diphtheritic  exudate  is 
much  less  general  than  Bretonneau  thought;  the  cases  of 
croup  ascending  and  those  of  coryza  and  otitis,  consecutive 
to  angina,  are  common.  We  do  not  see  what  action  the  acrid 
liquid,  if  it  did  exist,  could  exercise  under  these  circumstances; 
without  considering  that  gravity  and  the  movements  of  deglu- 


PATHOLOGICAL    ANATOMY.  75 

tition  bring  it  into  the  oesophagus,  the  mucous  membrane 
of  this  tube  should  figure  among  the  points  most  affected ; 
now,  nothing  is  less  true  ;  this  organ  is  so  rarely  attacked  by 
diphtheria  that  the  presence  of  the  concretions  on  its  surface 
has  been  emphatically  denied. 

This  theory  had  produced  a  special  plan  of  treatment,  which 
consisted  in  cauterizing  extensively,  unmercifully,  with  a  sauv- 
age  energie,  the  points  attacked  with  diphtheritic  exudation, 
with  the  object  of  concentrating  and  destroying  the  morbid 
principle  on  the  spot.  A  false  principle  leads  necessarily  to  a 
defective  practice  ;  and  the  talent  of  Trousseau  was  able  to 
save  neither  the  one  nor  the  other  from  the  discredit  into  which 
they  have  both  fallen. 

However  that  may  be,  the  false  membrane  is  constituted 
and  follows  the  cycle  of  its  evolution.  But  it  happens  some- 
times that  the  disease  not  having  exhausted  its  efforts,  forms 
in  the  diseased  mucous  membrane  a  new  action  which  is  itself 
followed  by  a  second  exudation  and  which  insinuates  itself 
under  the  patch  already  formed  and  lines  it  with  a  second 
layer.  When  several  times  reproduced  these  impulses  produce 
new  fibrinous  layers,  which  are  superimposed  and  give  to  the 
false  membrane  the  stratified  appearance. 

In  the  gangrenous  form  the  inflammatory  action,  much  more 
intense,  results  in  a  profound  infiltration  of  the  mucous  or 
cutaneous  corium  with  fibrin  and  young  cells,  an  infiltration 
which  compromises  the  nutrition  of  the  tissue  invaded  and 
stamps  it  with  death.  Like  all  inflammatory  products  the  false 
membrane,  after  having  obtained  its  acme,  proceeds  towards 
its  end.  It  may  end  in  one  of  two  ways  :  it  separates,  or  it 
disintegrates.  The  separation  of  the  false  membrane  is  ac- 
complished under  the  following  circumstances :  the  inflamma- 
tion of  the  mucous  membrane  declines,  the  vascular  walls  be- 
come strengthened ;  the  altered  portions  of  the  epithelium  are 
restored  ;  the  mucous  secreted  anew  interposes  itself  between 
the  exudate  and  the  mucous  membrane ;  the  filaments  which 
united  the  two  surfaces  are  broken;  the  false  membrane  grad- 
ually loses  its   adherence  and  is  detached.     At  the  same  time 


76  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

some  important  changes  are  established  in  its  composition.  At 
first  decidedly  fibrillary,  like  the  clot  after  venesection,  the 
fibrin  of  the  false  membrane  loses  its  fibrillary  character,  as 
occurs  in  all  coagulated  fibrin  after  a  considerable  time.  At 
the  end  of  four  or  five  days  the  fibrillary  condition  has  com- 
pletely disappeared  or  is  found  only  imperfectly  and  on  very 
limited  points.  It  is  replaced  by  the  granular  condition.  More- 
over, the  fibrin  may  also  be  transformed,  partially  at  least, 
into  mucin;  but  the  most  important  change  that  it  undergoes 
is  the  return  to  a  fatty  condition.  These  modifications  explain 
how  the  false  membrane  may  soften,  become  pulpous,  wear 
away,  disintegrate  and  disappear  before  reaching  a  separation 
en  masse. 

When  the  inflammation  has  reached  a  degree  sufficiently 
violent  to  produce  necrosis  (gangrene)  the  morbid  product  is 
eliminated  as  eschars  are.  The  facility  with  which  the  false 
membranes  separate  varies  also  according  to  the  region. 

In  the  pharynx  the  thickness  of  the  epithelium  and  its  con- 
nection with  the  corium  enable  the  two  parts  to  be  invaded 
at  once ;  there  is  therefore  deeper  penetration,  and  also  a 
greater  adherence  of  the  plastic  product  to  the  subjacent  tis- 
sues. 

In  the  hypo-glottic  portion  of  the  larynx  and  in  all  the  res- 
piratory tract,  the  false  membrane  is  more  superficial,  it  is  never 
intimately  united  to  the  corium  from  which  the  amorphous 
lamella  or  membrane  of  Bowman  separates  it.  Hence  it  is 
much  more  easily  detached.  The  detachment  occurs  in  a  period 
of  time  varying  between  two  and  fifteen  days.  It  commences 
from  the  second  to  the  tenth  day  and  ends  from  the  ninth  to 
the  fifteenth.  But  successive  exudations  may  be  produced. 
It  is  thus  that  I  have  found  false  membranes  in  an  autopsy 
made  on  the  thirty-first  day  from  the  outset.  I  have  seen  a 
patient  attacked  with  croup  expel  false  membranes  up  to  the 
thirty-second  day. 


pathological  anatomy.  77 

Sec.  2. — Supports  of  the  False  Membrane. 

I.  The  Miico2is  Membrane. — I  have  shown  in  the  preceding 
chapter  the  divergences  which  appear  among  authors  on  the 
subject  of  the  condition  of  the  mucous  membrane:  some  re- 
gard it  as  always  healthy  or  admit  only  slight  lesions  ;  others 
regard  it  as  profoundly  affected,  always  degenerated  and  often 
mortified.  The  ancients,  believing  in  a  gangrenous  process, 
looked  upon  the  false  membrane  as  an  eschar ;  Bretonneau 
showed  that  it  was  only  an  inflammatory  product  coming  from 
the  mucous  membrane.  Opposing  too  strongly  the  doctrines 
of  his  predecessors,  he  affirmed  the  absolute  integrity  of  the 
mucous  membrane  in  all  cases.  "  Most  frequently,"  said  he, 
"the  mucous  membrane  preserves  its  polish  and  its  ordinary 
consistence."     Elsewhere,  he  insists  in  this   language  : 

"In  no  case,  even  when  malignant  angina  had  assumed  the 
most  repulsive  character,  have  I  ever  been  able  to  discover 
anything  which  resembles  a  gangrenous  lesion.  Ecchymoses 
of  limited  extent,  as  well  as  a  slight  erosion  of  the  surfaces 
on  which  the  duration  of  the  malady  was  prolonged,  were  the 
gravest  alterations  that  I  succeeded  in  establishing."  He  was 
careful  to  secure  the  observer  against  possible  anatomical  er- 
rors. Tumefaction  of  the  mucous  membrane  and  of  the  sub- 
mucous tissue  which  surrounds  the  pseudo-membranous  patch- 
es might,  he  said,  if  one  was  not  on  his  guard,  cause  the  latter 
to  be  taken  for  ulcerations. 

The  opinion  of  Bretonneau,  founded,  no  doubt,  upon  the 
special  characteristics  of  the  epidemics  which  he  observed, 
has  found  numerous  opponents. 

Bequerel,  Isambert,  Bouillon-Lagrange,  Barthez  and  Rilliet, 
H.  Roger,  Laboulbene  and  Trousseau  have  proved  by  numerous 
facts  that  the  gangrenous  and  ulcerous  process  might  coincide 
with  diphtheria.  The  fact  was  well  established  when  Germany, 
returning  to  the  ideas  which  prevailed  before  Bretonneau, 
undertook  to  give  them  currency  once  more.  More  recent 
works  emanating  from  the  same  country  have  shown  wherein 
this  attempt  was  extreme. 

The  mucous  membrane,  in  my   opinion,  behaves   differently 


78  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

in  simple  cases  and  in  those  in  which  the  infectious  element 
predominates.  French  authors  have  written  that  the  condition 
of  the  mucous  membrane  and  the  appearance  of  the  false 
membrane  varied  according  as  the  diphtheria  was  priviary  or 
secondajy;  they  have  consequently  adopted  this  division  as 
the  basis  of  their  description.  I  have  not  admitted  this  view, 
for  the  reason  that  these  differences  hold  essentially,  not  to 
the  primary  or  secondary  character  of  the  disease,  but  to  the 
degree  of  intensity  and  to  its  simple  or  its  infectious  nature. 
In  fact,  while  certain  grave  local  characteristics  present  them- 
selves often  and  in  a  high  degree  in  secondary  diphtheria,  they 
are  not  inseparable  from  it,  and  we  see  them  but  too  frequent- 
ly in  the  primary  form.  It  is,  therefore,  rational  to  examine 
the  modifications  which  the  mucous  membrane  and  the  sub- 
mucous tissues  undergo  in  the  simple  cases  as  well  as  in  those 
in  which  the  disease  is  intense  and  infectious.  In  the  begin- 
ning the  mucous  membrane  is  red  and  hypersemic ;  in  some 
eases,  according  to  Daviot,  it  presents  a  transparent  oedema- 
tous  aspect.  The  capillaries  are  dilated,  arborescent  or  form 
small  dotted  spots.  Their  walls  become  altered  and  permit 
the  leucocytes  and  fibrin  to  transude.  The  leucocytes  im- 
pregnate the  mucous  membrane  to  a  considerable  depth  and 
upon  a  surface  extending  beyond  that  occupied  by  the  false 
membrane.  The  fibrin  is  distributed  according  to  the  case, 
and  especially  according  to  the  intensity  of  the  process.  In 
the  mild  forms  it  is  deposited  on  the  surface  of  the  epithelium 
in  the  form  of  a  white  pellicle,  which  becomes  thickened  and 
hardened.  In  the  grave  form,  and  according  to  the  region,  it 
is  infiltrated,  superficially  or  profoundly,  into  the  structure  of 
the  corium,  suspends  nutrition  in  these  parts,  mortifies  them 
and  forms  with  them  an  eschar  which  is  eliminated  by  the 
ordinary  process.  When  the  false  membrane  is  constituted, 
the  mucous  membrane  remains  for  a  certain  time  congested, 
but  smooth,  rarely  uneven. 

The  mucous  membrane  and  its  morbid  product  adhere 
strongly  to  one  another,  they  are  separable  only  with  some 
difficulty,  and  only  at  the  expense  of  a  slight  escape  of  blood. 


PATHOLOGICAL    ANATOMY.  79 

Little  by  little  the  congestion  diminishes,  the  mucous  mem- 
brane returns  to  its  normal  state  and  the  false  membrane  sep- 
arates, carrying  with  it  a  large  part  of  the  epithelium.  The 
latter  is  replaced  at  the  end  of  a  short  time. 

In  the  more  intense  cases  of  the  disease,  the  congestion  is 
accompanied  with  tumefaction,  infiltration  of  the  mucous 
membrane  and  of  the  cellular  tissue  in  a  certain  zone  around 
the  false  membrane  ;  the  latter  appears  to  be  situated  at  the 
bottom  of  a  depression.  The  mucous  membrane  is  rugose, 
roughened,  and  there  are  formed  on  its  surface  ecchemoses 
which  discolor  the  false  membrane  and  spot  it  with  brown. 

Ulcerations  of  various  forms  and  dimensions  may  appear  on 
the  surface.  Sometimes  round,  sometimes  sinuous,  which 
makes  them  resemble,  according  to  the  comparison  of  Barthez 
and  Rilliet,  moth-eaten  cloth,  they  show  clean-cut  margins, 
not  separated  or  detached.  The  base  is  constituted  of  mus- 
cular fibers  frequently  changed,  as  modem  investigations  show, 
contrary  to  ancient  opinion.  In  the  violent  and  infectious 
forms,  the  tumefaction  and  oedema  become  considerable,  the 
ecchemotic  discoloration  more  pronounced  and  the  infiltration 
of  fibrin  and  leucocytes  increase  in  the  structure  of  the  mu- 
cous corium.  The  mucous  membrane  becomes  uneven,  rough- 
ened (shagreened);  it  softens,  mortifies  and  becomes  covered 
with  large  grey  or  brown  ulcerations,  with  the  margins  de- 
tached, coated  with  a  greenish  gray  detritus,  the  whole  exhal- 
ing the  fetor  characteristic  of  gangrene.  The  tonsils,  uvula, 
soft  palate  and  its  pillars  are  the  parts  most  frequently  morti- 
fied. The  mucous  membrane  of  the  larynx  and  trachea  is 
affected  much  more  rarely. 

The  gangrenous  process  varies  in  proportion  to  its  intensity. 
Most  frequently  it  attacks  but  a  part  of  the  thickness  of  the 
mucous  membrane;  but  in  others  it  goes  beyond  the  limits  of 
this  membrane,  invades  the  subjacent  cellular  tissue,  and  even 
the  neighboring  muscles.  In  a  patient  attacked  with  diph- 
theritic angina  of  the  gangrenous  form,  the  detachment  of  the 
eschars  revealed  several  perforations  of  the  soft  palate.  The 
disease  not  having  been  either  preceded  by  nor  accompanied 


8o  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

with  rubeola  or  any  other  morbid  condition  impelling  to  gan- 
grene, diphtheria  could  be  alone  chargeable  with  the  un- 
usual intensity  of  this  gangrenous  process.  The  mortification 
has  also  been  seen  to  progress,  step  by  step,  to  the  vicinity  of 
the  large  vessels. 

In  the  cases  less  grave  the  ulcerations  heal,  but  they  leave 
in  their  place  a  cicatricial  tissue,  the  retraction  of  which  causes 
deformities  and  strictures  which  may  produce  obstacles  to  the 
action  of  the  pharynx,  the  larynx  and  the  trachea.  The  sub- 
vmcous  tissue  is  also  affected  by  extension  of  the  lesions  of  the 
mucous  membranes.  In  the  simple  cases  it  is  infiltrated  with 
young  cells.  In  the  grave  cases  it  participates  in  the  inflam- 
matory and  gangrenous  processes  of  which  the  mucous  mem- 
brane becomes  the  seat. 

2.     The  Skin. 

Like  the  mucous  membrane,  the  skin  serves  as  a  substratum 
to  the  diphtheritic  pseudo-membranes.  I  shall  not  occupy 
myself  in  this  chapter  with  the  appearances  of  the  disease,  but 
shall  confine  myself  to  the  description  of  its  anatomical  alter- 
ations. 

The  exudation  presents  itself  most  frequently  upon  the  skin 
deprived  of  the  superficial  layer  of  the  epidermis  and  upon 
ulcerated  and  excoriated  surfaces,  and  those  covered  with 
eruptions. 

The  dermis  which  supports  the  false  membranes  is  indu- 
rated, thickened,  red,  uneven  and  granulated  on  its  surface. 
The  margins  of  the  injury  are  quite  prominent  and  of  a  vio- 
let red ;  the  subcutaneous  connective  tissue  is  infiltrated  and 
tumefied. 

These  alterations  affect  the  surrounding  skin  to  a  certain  ex- 
tent. Upon  this  inflamed  surface  the  epidermis  rises,  vesicles 
and  bullae  form,  filled,  most  frequently,  with  a  milky  serosity. 
By  incising  this  epidermis  the  deep  surface  appears  covered 
with  a  false  membrane  in  process  of  formation  or  completely 
formed,  according  to  the  period.  It  is  by  this  mechanism  and 
by    the     agglomeration    of  these  phylctenulse  that  the  diph- 


PATHOLOGICAL    ANATOMY.  8 1 

theria  extends.  In  some  cases  the  disease  assumes  a  greater 
intensity  and  takes  on  the  gangrenous  form ;  and  to  the  false 
membranes  are  then  added  the  lesions  peculiar  to  gangrene, 
viz.,  eschar,  fetor  and  a  peculiar  discoloration. 

The  histological  part  presents  nothing  new.  The  alterations 
of  the  skin  are  analogous  to  those  of  the  mucous  membrane. 
The  rete  nmcosuni  of  Malpighi  and  the  superficial  layer  of  the 
corium,  which  present  so  much  correspondence  with  the  epi- 
thelium and  the  corium  of  the  mucous  membranes,  serve  as 
the  seat  of  the  process   and  present  lesions  of  the  same  kind. 

The  mode  of  formation  of  the  false  membrane  is  the  same, 
as  well  as  its  structure. 


SECOND    CLASS— LESIONS  OF  THE  APPARATUS- 
LOCALIZATION  OF  THE  FALSE  MEMBRANE- 
SECONDARY  LESIONS. 


Section  I.     Lymphatic  Glands. 


It  is  very  rarely  in  diphtheria  that  the  neighboring  lym- 
phatic ganglions  or  glands  remain  in  a  state  of  integrity.  All 
superficial  ganghons  are  amenable  to  adenitis,  but  especially 
those  of  the  neck,  among  which,  in  a  pre-eminent  degree,  are 
the  submaxillary  and  the  parotid.  It  is  to  these  that  the  dis- 
ease extends  most  frequently  and  with  the  greatest  intensity. 
In  certain  regions  the  deep  ganglions  may  become  afTected 
after  the  superficial  ones;  in  the  neck  this  is  the  case  especially 
with  those  following  the  course  of  the  sterno-mastoid. 
Lesions  of  the  cervical  ganghons  have  been  pointed  out  by 
numerous  authors,  but  there  are  other  ganglions  of  which  the 
morbid  condition  is  less  known ;  I  refer  to  the  bronchial  and 
also  to  the  mesenteric  glands. 

In  a  large  number  of  cases,  dead  of  croup,  I  have  seen  at 
the  autopsy  the  tracheal  and  bronchial  ganglions  present 
lesions  varying  from  simple  tumefaction  to  suppuration.  These 
cases  of  adenitis  present    nothing  peculiar;  their  anatomical 


82  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

characteristics  are  the  same  as  those  of  adenitis  in  general. 
Increase  of  volume  and  redness  on  section  are  the  most  com- 
mon conditions  of  the  ganglions.  At  a  more  advanced  period 
the  redness  becomes  darker  and  the  parenchyma  becomes  like 
that  of  the  spleen,  and  later  becomes  infiltrated  with  a  some- 
what abundant  milky  serosity.  Finally,  when  the  diphtheritic 
manifestation  is  very  intense — it  is  almost  invariably  in  angina 
that  this  termination  is  observed — the  gland  suppurates.  In  its 
tissue  are  formed  purulent  nodules  isolated  or  united  into  a 
single  focus. 

When  the  ganglions  are  affected  in  large  number  they  some- 
times form,  by  agglomeration,  tumors  of  considerable  size  of 
which  their  importance  depends  upon  the  relation  they  sustain 
to  the  neighboring  organs.  Among  the  possible  consequences 
may  be,  projection  into  the  pharynx  and  stricture  of  its  cavity; 
compression  of  the  larynx,  the  trachea  or  the  bronchi;  or 
strangulation  of  the  vessels  ;  these  are  their  possible  conse- 
quences. I  have  published  the  case  of  a  patient  in  whom  an 
enormous  double,  submaxillary  adenitis,  accompanying  a  scar- 
latinous diphtheria,  gave  rise,  in  consequence  of  the  obstructed 
circulation  which  it  produced,  to  an  oedema  of  the  glottis  which 
necessitated  tracheotomy. 

The  surrounding  connective  tissue  which  envelops  the  gan- 
glions does  not  remain  indifferent  to  their  morbid  condition. 
It  participates  in  it  at  times  with  a  surprising  intensity.  In 
the  simple  cases,  it  is  only  hyperemic  and  tumefied. 

In  cases  more  grave  there  occurs  a  true  inflammatory 
oedema  which  gives  to  the  part  a  doughy  consistence,  but  hard 
at  the  same  time.  The  skin  assumes  that  shiny  aspect  which 
it  acquires  when  it  is  strongly  distended ;  and  it  pits  on  press- 
ure. When  the  adenitis  is  very  intense  the  connective  tissue 
suppurates  and  we  find  in  it  scattered  points  or  large  purulent 
pouches  in  which  the  diseased  glands  float.  One  thing  re- 
markable is,  that  the  lesions  of  the  ganglions  are  frequently 
more  tardy  than  those  of  the  connective  tissue.  While  the  lat- 
ter is  in  complete  suppuration,  it  may  happen  that  the  glandu- 
ular  inflammation  may  have  been  arrested  in  its  course.   W'hen 


PATHOLOGICAL    ANATOMY.  83 

suppuration  occurs  in  both  tissues  it  forms  two  collections  of 
unequal  volume,  the  superficial  one  is  of  much  the  greater  ex- 
tent. They  are  united  by  a  quite  narrow  track,  and  constitute 
In  their  entirety  the  variety  known  by  the  name  of  abces  en 
bouton  de  chemise. 

Section  II.     General  Connective  Tissue. 

The  general  sub-cutaneous  connective  tissue  is  most  frequently 
healthy ;  however  it  must  be  noted  that  an  anasarca  may  oc- 
cur, though  very  rarely,  in  the  train  of  albuminuria.  Sangui- 
nolent  effusions  also  occur  in  its  substance.  In  a  patient  tra- 
cheotomized  on  account  of  croup,  in  whom  the  flaps  were 
attacked  with  gangrene,  I  recognized  the  existence  of  a  small 
subcutaneous  bloody  effusion  situated  behind  one  ear.  Bou- 
chut  has  quite  frequently  witnessed  these  extravasations ;  in 
forty-six  autopsies  he  saw  them  twenty-six  times,  as  well  in 
the  connective  tissue  as  in  the  muscles. 

Section  III.     Digestive  Apparatus. 

The  throat  is,  beyond  qusstion,  the  site  of  election  of  diph- 
theria; and  of  all  the  manifestations  of  this  disease,  angina  is 
the  most  common.  We  must  not  suppose,  however,  that  the 
other  parts  of  the  digestive  tube  are  always  free.  The  ana- 
tomical lesions  of  which  I  shall  speak  in  this  section  are  not 
numerous.  The  general  remarks  upon  the  false  membranes 
and  upon  the  mucous  membrane  and  the  neighboring  tissues, 
having  been  given,  it  remains  only  to  speak  of  loca.'  oeculiari- 
ties.  Now,  the  most  important  regions  of  this  apparatus  being 
visible,  the  pathological  anatomy  is  blended  largely  with  the 
description  of  the  local  symptoms.  To  avoid  repetition  I  shall 
reserve  the  latter  part  of  this  description  for  the  chanter  on 
symptoms,  where  it  will  find  its  proper  place. 

I  shall  limit  myself,  for  the  present,  to  some  brief  indica- 
tions. 

Diphtheria  of  the  Mouth  exists  beyond  doubt.  It  occurs  in 
much  less  relative  frequency,  however,  than  was  supposed  by 
Bretonneau  and  Trousseau,  who  confounded  with  it  that  path- 


84  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

ological  species  so  different,  known  under  the  name  of  tdcero- 
nionhranons  stomatitis.  Any  part  of  the  mouth  may  become 
the  seat  of  false  membranes  ;  the  Hps,  upon  their  borders,  their 
commissures  and  their  posterior  surfaces;  the  cheeks,  and 
the  tongue.  Gangrene  of  these  parts  is  rare ;  the  mucous 
membrane  is  attacked  superficially.  The  tongue,  however,  is 
an  exception.  Upon  this  organ  the  mucous  membrane  is  often 
invaded,  and  recovers  with  a  cicatrix.  Hayem  insists  correctly 
upon  this  point. 

The  istlinms  of  the  fauces  is  indifferently  attacked  at  all 
points.  The  tonsils,  the  soft  palate  with  its  pillars,  and  the 
pb^rvnx,  may  be  separately,  simultaneously  or  successively 
covered  with  diphtheritic  exudates.  The  different  forms,  sim- 
ple, ulcerous  and  gangrenous,  are  there  met  with  in  all  their 
varieties.  The  latter  two  concern  the  pathological  anatomy  by 
the  deep  destruction  of  which  they  are  the  cause.  The  false 
membranes  form,  with  the  subjacent  tissues,  a  sloughy  pulp. 
The  uvula  and  the  tonsils  are  ragged,  infiltrated  with  pus,  and 
are  on  the  point  of  being  detached ;  the  soft  palate  itself  may 
be  perforated,  as  the  observation  cited  on  p.  79  may  prove 
[and  as  I  have  seen].  In  another  case  one  tonsil  contained  a 
large  purulent  sac.  In  a  third,  the  tonsils  had  disappeared, 
nothing  remaining  in  their  place  but  a  brown  consistent  sac 
enclosed  between  the  pillars,  containing  in  its  cavity  a  semi- 
liquid,  greenish  substance,  with  gangrenous  odor.  From  the 
point  where  the  mucous  membrane  ceases  to  be  exposed  to 
the  external  air  the  false  membranes  become  very  rare,  so  ex- 
ceptional, indeed,  that  their  existence  in  these  regions  has  been 
.doubted  by  Empis  and  Isambert. 

However,  some  observers  of  high  repute  having  described 
de  visit  these  lesions,  we  are  obliged  to  admit  their  existence, 
however  rare  they  may  be.  Let  us  then  examine  them  in  the 
various  divisions  of  the  digestive  tube.  In  the  a;sophagiis  they 
present  themselves  under  different  forms;  at  one  time  like 
bands,  lining  the  posterior  wall  of  this  tube,  part  of  or  its  en- 
tire length,  even  extending  into  the  stomach ;  at  another  they 
are  in  the  form  of  complete  or  incomplete  tubes  ( Vidal).     To 


PATHOLOGICAL    ANATOMY.  8$ 

these  cases  I  can  add  a  personal  observation.  In  a  child  dead 
of  diphtheria  of  the  throat  and  tongue,  the  autopsy  revealed  a 
yellow  false  membrane,  thick  and  cylindrical,  lining  the  su- 
perior half  of  the  oesophagus.  In  the  stomach  they  are  still 
more  rare,  forming  in  this  cavity  thin  filaments  or  even  bands, 
running  from  the  cardia  to  the  pylorus. 

In  the  intestines  they  are  mentioned  by  Roche,  who  observed 
them  twice ;  in  each  case  the  patient  was  attacked  with  mem- 
branous angina  or  croup.  Guersant,  Bretonneau,  Guibert  and 
Louis  have  also  cited  examples  observed  under  the  same  cir- 
cumstances. Finally,  diphtheria  of  the  anus  is  mentioned  by 
I'Espine,  who  observed  it  during  an  epidemic  which  prevailed 
at  the  military  hospital  of  La  Fleche.  I  have  also  seen  two 
cases  of  it.  The  exudate  is  disposed  in  separate  or  in  conflu- 
ent patches  which  may  ascend  into  the  rectum.  Anatomical 
lesions,  independent  of  the  false  membrane,  have  their  seat  in 
the  digestive  tube  or  its  appendages.  Redness  and  tumefac- 
tion of  the  patches  of  Peyer  are  quite  frequently  encountered. 
But  these  alterations  are  of  little  importance.  They  have  been 
found,  in  children,  independently  of  typhoid  fever,  and  in 
many  morbid  conditions,  such  as  scarlatina,  measles,  etc. 

On  the  other  hand,  they  do  not  attend,  in  primary  diph- 
theria, a  collection  of  special  symptoms.  They  are  discovered 
frequently  at  the  autopsy  without  any  morbid  phenomena  hav- 
ing attended  them.  In  a  case  in  which  they  existed  with  mes- 
enteric adenitis  there  had  not  been,  during  life,  any  abdomi- 
nal symptom  or  typhoid  fever.  These  cases  do  not  appear  to 
enter,  in  any  manner,  into  whatTraube  calls  typhoid  diphtheria, 
a  form  which  is  characterized,  among  other  symptoms,  by 
tumefaction  of  the  spleen  and  a  roseolar  eruption. 

On  the  contrary.  Dr.  Blanchetiere  found  in  two  cases  altera- 
tions of  Peyer's  patches ;  but  in  these  two  patients  diphtheria 
had  appeared  in  the  course  of  an  attack  of  typhoid  fever,  on 
the  twentieth  or  twenty-third  day.  It  was  not,  therefore,  ty- 
phoid diphtheria,  but  secondary  diphtheria  with  typhoid  fever. 
In  an  observation  by  Parrot,  cited  by  Beau  Verdeny,  it  was 
the  case  of  a  child  attacked  with  croup,  which  suffered  at  the 


86  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

same  time  with  severe  diarrhoea,  accompanied  with  rose  spots 
and  duhiess  (submatite)  on  percussion  in  the  right  iHac 
fossa.  SwelHng  and  redness  of  Peyer's  glands  were  found. 
Wilson  believes  that  diphtheria  of  the  throat  is  always  consec- 
utive to  a  disease  of  the  stomach  (?).  In  New  Zealand  he  ob- 
served gastric  symptoms  before  angina.  At  the  autopsy  he 
found  lesions  of  the  stomach. 

The  liver  is  often  altered.  In  many  autopsies  I  have  found 
a  certain  degree  of  fatty  degeneration  of  this  organ.  Most 
frequently  we  find  some  superficial  patches  ;  in  other  cases  they 
are  in  the  form  of  foci,  occupying  the  depth  of  the  organ, 
the  surface  escaping  or  not.  In  two  cases  the  hepatic  tissue 
was  completely  fatty ;  one  of  the  two  livers  was  very  large.  In 
another  patient  a  perihepatitis  of  the  convex  surface  of  the 
liver,  with  diaphragmatic  adhesion,  existed. 

Blanchetiere  observed  in  the  practice  of  Labric  a  case  of 
fatty  alteration  in  islets.  In  the  thesis  of  Beau  Verdeny  it  is 
also  stated  that  fatty  degeneration  of  the  liver,  more  or  less 
profound,  was  found  in  nine  observations  out  of  twenty-six. 
These  transformations  of  tissue  have  nothing  in  them  peculiar 
to  diphtheria;  they  are  common  to  all  maladies  which  pro- 
foundly affect  the  economy,  namely,  fevers  and  certain  kinds 
of  poisoning. 

Section  IV. — Respiratory  Apparatus. 

The  entire  respiratory  tract  may  be,  primarily  or  secondarily, 
affected  by  diphtheria;  primarily,  by  the  false  membranes 
which  extend  upon  the  respiratory  mucous  membrane ;  sec- 
ondarily, by  the  lesions  which,  without  being  pseudo-membran- 
ous, are  closely  connected,  by  virtue  of  complications,  with 
the  diphtheritic  process.  Every  part  of  the  respiratory  appar- 
atus is  subject  to  these  morbid  manifestations. 

I.     The  Nose  and  the  Nasal  Foss^. 

Barthez  and  Rilliet  have  given  an  excellent  description  of 
pseudo-membranous  coryza.  Bretonneau,  Isambert  and  La- 
boulbene  have  also  touched  uqon  this  question.     The  exudate 


PATHOLOGICAL   ANATOMY.  8/ 

occupies  a  variable  extent ;  it  forms  patches,  at  one  time  small 
and  scattered,  at  another  broad  and  extended,  which  are 
molded  upon  the  turbinated  bones  and  into  the  meatuses, 
penetrating  into  the  sinuses,  especially  the  upper  maxillary, 
and  covering  the  entire  extent  of  the  Schneiderian  mucous 
membrane.  It  exceeds  the  limits,  also,  of  the  nasal  fossa,  of 
the  side  which  it  invades,  either  posteriorly  or  anteriorly. 
Often  but  slightly  adherent,  but  thick  and  resistant,  it  is  of  a 
yellowish  white.  Its  under  surface  is  sometimes  ecchemosed 
and  beset  with  papillae  like  those  on  the  end  of  the  tongue 
(Bretonneau);  these  are  prolongations  which  penetrate  into  the 
orifices  of  the  muciparous  glands.  The  mucous  membrane  is 
inflamed,  red  and  thick  ;  but  in  no  case  has  it  been  proved  to 
be  ulcerated.  A  fetid  muco-prurulent  fluid  bathes  the  parts. 
Diphtheria  is  rarely  limited  to  the  nasal  fossae,  false  membranes 
appear  almost  always  upon  other  points,  to-wit,  the  pharynx, 
larynx,  bronchi,  etc. 

2.     Larynx. 

Some  peculiarities  of  disposition  only  deserve  to  be  men- 
tionen.  The  diphtheritic  pellicle  which  is  met  with  in  the 
larynx  may  be  isolated,  but  more  frequently  it  is  prolonged 
into  the  pharynx  or  into  the  trachea.  The  epiglottis  and  the 
aryteno-epiglottic  ligaments  are  its  favorite  sites.  When  in  con- 
tact with  both  surfaces  of  the  epiglottis,  it  completely  covers 
this  organ,  and  then  extending  upon  the  aryteno-epiglottic  lig- 
aments, it  forms  at  their  margins  swellings  which  contract  the 
orifice  of  the  larynx.  It  is  rare  to  find  the  false  membranes 
acquiring  such  a  thickness  as  to  completely  obstruct  the  larynx. 

However,  asphyxia  does  not  require  an  absolute  occlusion 
of  the  passage  ;  it  appears  when  the  disturbances  of  haematosis 
#have  acquired,  at  length,  a  sufficient  intensity.  But  though 
the  pseudo-membranous  coating  rarely  suffices  to  close  the 
larynx,  it  does  occur  that  fragments,  falling  from  above,  act  the 
part  of  a  plug.  The  age,  and  consequently  the  dimensions  of 
the  larynx,  greatly  influence  the  permeability  left  by  the  diph- 
theretic  coating.     An  adult  larynx  is  but  seldom  filled  up  even 


88  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

by  thick  false  membrane,  while  a  thin  one,  relatively,  is  suffi- 
cient to  close  hermetically  that  of  a  young  child.  From  the 
aryteno-epiglottic  ligament,  the  pseudo-membrane  reaches  the 
true  larynx,  passes  round  the  vocal  cords,  extends  into  the  ven- 
tricles and  penetrates  the  trachea.  The  larynx  is  not  always 
lined  throughout  its  entire  extent  with  false  membrane,  the 
hypo-glottic  portion  is  more  frequently  attacked.  The  degree 
of  adherence  and  of  thickness  of  the  false  membranes  differs 
in  many  cases.  However,  those  of  the  hypo-glottic  portion 
adhere  more  firmly  to  the  subjacent  parts.  Upon  its  free  sur- 
face the  false  membrane  is  most  frequently  of  a  whitish  yellow, 
but  it  may  present  all  the  varieties  indicated  in  the  general 
description.  Its  deep  surface  sends  numerous  projections  into 
the  mucous  membrane ;  sometimes  it  is  ecchymosed. 

The  mucous  membrane  is  at  times  red  and  inflamed,  at 
others  tumefied  and  softened,  but  seldom  ulcerated  or  morti- 
fied. Ulceration  is  more  common  in  the  hyper-glottic  portion ; 
it  is,  however,  to  be  seen  also  in  the  hypo-glottic  part ;  it  gen- 
erally coincides  with  a  similar  lesion  of  the  trachea  or  with 
gangrene  of  the  wound  resulting  from  tracheotomy.  I  have 
showed  it,  however,  of  the  size  of  a  half  dime,  and  situated 
below  the  vocal  cords  in  a  patient  who  had  died  of  croup  with- 
out having  been  operated  on.  In  one  case  it  was  located  on  a 
level  with  the  inferior  vocal  cords ;  on  one  side  it  was  super- 
ficial, but  on  the  other  it  had  destroyed  the  mucous  membrane 
and  left  the  thyro-arytenoid  muscle  exposed.  The  tumefac- 
tion may  be  considerable ;  I  have  seen  it  sufficiently  devel- 
oped, on  a  level  with  the  inferior  vocal  cords,  to  greatly  dimin- 
ish the  calibre  of  the  glottis.  Under  certain  circumstances, 
very  rare  by  the  way,  one  observes,  instead  of  simple  tumefac- 
tion, infiltration  of  the  mucous  membrane  and  of  the  subjacent 
tissues,  the  oedema  of  the  glottis.  One  case  has  been  mentioned  s 
by  Messrs.  Barthez  and  Rilliet,  and  another  by  Bouchut.  Five 
cases  came  under  my  observation,  the  first  being  a  case  of 
croup  without  angina.  While  a  false  membrane  covered  uni- 
formly the  larynx,  the  epiglottis  and  the  aryteno-epiglottic  lig- 
aments were  oedematous.     In  the  second,  the  laryngeal  oedema 


PATHOLOGICAL    ANATOMY.  89 

followed  a  diphtheritic  angina  without  croup.  One  could  still 
find  some  pseudo-membranous  remains  upon  the  tonsils,  but 
the  air-passages  were  free  of  them.  The  aryteno-epiglottic 
ligaments  and  the  margins  of  the  epiglottis  formed  thick, 
dense  and  tremulous  swellings.  By  pressure  a  few  drops  of 
turbid  serosity  would  exude  from  the  incised  surface.  The 
third  was  discovered  sixteen  days  after  the  commencement  of 
an  operated  croup  case.  The  patient  died  of  albuminuria, 
with  anasarca,  pulmonary  oedema,  and  bronchitis.  Whenever 
an  attempt  was  made  to  remove  the  canula,  violent  attacks 
of  suffocation  compelled  its  replacement.  The  epiglottis  and 
the  aryteno-epiglottic  ligaments  presented  the  same  appear- 
ances as  described  above.  Another  case  occurred,  after  an 
abscess,  anterior  to  the  larynx,  developed  as  the  result  of  tra- 
cheotomy. 

The  muscles  of  the  laryjtx  often  present  alterations  in  their 
structure;  unrecognized  by  most  authors  they  are  pointed  out 
in  a  general  way  by  Niemeyer.  Rokitanski  states  that  these 
muscles  are  pale,  softened,  infiltrated,  and  consequently  incapa- 
ble of  efficient  contraction.  Zenker,  while  admitting  the 
paralysis,  doubts  the  changes  in  the  muscular  tissue.  Charcot 
and  Vulpian,  while  examining  a  case  of  diphtheritic  paralysis, 
found  local  changes  of  the  laryngeal  nerves  and  partial  fatty 
degeneration  of  the  muscles. 

It  is  not  only  at  a  period  remote  from  the  commencement 
that  these  muscular  lesions  are  discovered,  but  they  are  also 
met  with  in  the  acute  stage.  They  have  been  stated  by  Quin- 
quaud  and  by  Callandreau  Dufresse.  The  extrinsic  muscles  of 
the  larynx  are  rarely  attacked,  or  in  a  slight  degree.  The  pos- 
terior arytenoid  muscles  are  rather  more  frequently  attacked 
than  the  preceding  ones ;  but  the  most  frequently  and  the 
most  profoundly  affected  are  the  thyro-arytenoidii.  Pale  or  of 
a  dark  brown  (dead-leaf),  these  latter  are  tumefied,  oedematous 
and  friable.  The  fibrillae  have  augmented  in  volume,  and  the 
striation  has  disappeared  ;  all  the  characteristics  of  fatty  de- 
generation are  revealed,  viz.,  granules  strongly  refracting  the 
light,  and  crowded  together,  rendered  more  apparent  by  the 


90  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

action  of  acetic  acid,  but  diminishing  and  disappearing  under 
the  action  of  ether  or  of  chloroform ;  and  in  some  fibres  there 
is  multipHcation  of  the  nuclei  of  the  myolemma.  It  looks  as 
if  one  was  dealing  with  phosphorous  fatty  degeneration. 
(Callendreau  Dufresse.)  All  the  fibrillae  are  not  so  pro- 
foundly changed ;  every  intermediate  degree,  even  to  a  healthy 
state,  may  be  met  with,  but  the  muscle  always  presents  in  its 
totality  numerous  lesions.  The  elucidation  of  this  anatomical 
point  is  fertile  in  pathological  applications;  it  facilitates  the 
explanation  of  certain  symptoms  in  croup  following,  early  or 
later,  the  attack,  and  gives  valuable  data  upon  the  action  of 
the  larynx  in  this  disease. 

Cartilages. — The  cartilages  of  the  larynx  occasionally  par- 
ticipate, by  extension,  in  the  inflammation  and  lesions  of  the 
parts  which  cover  them.  They  are  found  more  or  less  eroded. 
Delbet  speaks  of  a  child  attacked  with  gangrenous  angina  who 
spat  up  his  epiglottis.  Blanchetiere  describes  a  case  of  exten- 
sive necrosis  of  the  cricoid  and  the  thyroid  cartilages  follow- 
ing gangrene  of  the  wound  in  tracheotomy. 

3.     Trachea. 

Primary  diphtheritic  lesions  of  the  trachea  are  encountered 
in  every  form  and  degree.  The  false  membranes  are  here  de- 
veloped either  in  patches  of  various  dimensions  with  fre- 
quently irregular  margins,  or  are  in  the  form  of  cylinders 
which  occupy  a  part  or  the  whole  of  the  tube.  In  the  latter 
case  the  cylinder  often  extends  into  the  bronchi.  But  com- 
plete pseudo-membranous  tubes  lining  the  trachea  in  its  entire 
length  are  sufficiently  rare;  [see  plate  of  a  cast  opposite 
frontispiece] ;  it  is  particularly  in  the  superior  part  of 
this  passage,  and  following  that  of  the  larynx,  that  the 
false  membrane  is  deposited  circularly.  Further  down,  its 
edges  are  fringed  and  projected  into  points  more  or  less  ex- 
tended, which  often  terminate  in  filaments.  The  most  common 
variety  of  these  latter  follow  the  posterior  wall  of  the  passage 
and  divide,  at  a  level  with  the  bifurcation,  into  two  secondary 
bands  which  penetrate  deeply  into  the  bronchi.      The  false 


I 


PATHOLOGICAL    ANATOMY.  9I 

membrane  of  the  trachea  is  dense,  thicker  in  the  superior  por- 
tions than  in  the  inferior,  and  moderately  adherent.  The  mu- 
cous membrane  is  seldom  altered,  at  least  to  the  naked  eye. 
It  is  susceptible  to  the  same  lesions  as  that  of  the  larynx.  But 
there  is  a  class  of  ulcerations,  peculiar  to  the  trachea,  of  trau- 
matic origin,  produced  nearly  always  by  the  retention  of  the 
canula  after  tracheotomy.  They  demand  a  separate  descrip- 
tion. 

Ulceration  of  the  Trahcea. — Mentioned  by  Vidal,  Goupil,  and 
Barthez,  their  history  has  been  written  by  Roger.  I  have  de- 
voted one  chapter  of  a  former  work  to  this  interesting  part  of 
pathology.  The  most  common  site  of  this  ulceration  is  the 
anterior  wall  of  the  trachea  below  the  inferior  angle  of  the 
incision,  at  a  point  which,  during  hfe,  corresponded  to  the 
lower  end  of  the  canula ;  a  healthy  mucous  surface  generally 
separates  these  two  points ;  and  more  rarely  the  posterior  wall 
is  also  compromised ;  finally,  sometimes  the  entire  circumfer- 
ence is  implicated.  The  color  varies  from  grayish  white  to 
yellow,  sometimes  it  is  brown  or  greenish.  The  form,  in  sim- 
ple cases,  is  round  or  oval,  but  may  become  irregular.  The 
size,  which  often  does  not  exceed  that  of  a  lentil  or  of  a  half- 
dime  or  dime  piece,  becomes  much  extended  under  some  cir- 
cumstances. Roger  cites  a  case  of  ulceration  which  occupied 
two-thirds  of  the  length  of  the  trachea  in  its  entire  circumfer- 
ence. The  depth  varies  between  a  simple  erosion  of  the  mu- 
cous membrane  and  a  perforation  of  the  trachea.  Frequently 
it  corresponds  with  the  intensity  of  the  lesions  of  the  sur- 
rounding mucous  membrane,  that  is,  deep  ulcerations  are  ob- 
served in  the  midst  of  serious  destruction.  This  rule  has  ex- 
ceptions. One  finds  deep  ulcerations,  even  perforations,  which 
appear  excavated  as  with  a  punch  in  the  apparently  sound  tis- 
sue;  on  the  other  hand,  we  find  superficial  erosions  upon  tis- 
sues seriously  injured.  But  aside  from  these  deviations  from 
the  rule,  the  surrounding  mucous  membrane  is  yellow  and 
roughened  when  it  is  not  of  a  dark  gray  or  greenish.  It  is 
friable  and  comes  off  in  fragments.  The  bottom  of  the  ulcer- 
ation is  covered  with  mortified  debris  and  leaves  exposed  the 


92  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

denuded  cartilages.  These  lose  their  elasticity  and  resistance, 
become  attenuated,  sometimes  to  complete  destruction,  leav- 
ing no  protection  to  the  trachea  but  the  fibrous  coating. 
This  latter  barrier  itself  may  yield  and  the  perforatio7i  be  ef- 
fected. In  nearly  all  cases  the  perforation  is  made  in  the  an- 
terior wall  at  a  point  which  was  in  contact  with  the  lower 
extremity  of  the  tube. 

The  relations  which  this  portion  of  the  trachea  holds  with 
important  organs  add  much  interest  to  the  seat  of  this  lesion. 
I  have  cited  a  case  observed  at  the  Hospital  St.  Eugenie,  in 
which  two  large  perforations  existed,  of  which  the  innominate 
artery  formed  the  base.  In  another  the  perforation  was  not 
complete,  but  a  very  thin  cellular  layer  alone  intervened  be- 
tween the  end  of  the  canula  and  the  same  vessel  on  a  level  with 
its  bifurcation.  In  the  third  patient  three  perforations  of  the 
trachea  opened  communication  between  this  organ  and  the 
lower  portion  of  the  wound  of  the  integument,  itself  quite 
large.  One  of  the  patients  of  whom  Roger  speaks  had,  as  an 
exception,  a  perforation  of  the  posterior  tracheal  wall,  and  the 
ces®phagus  was  in  contact  with  the  opening.  The  starting 
point  of  the  ulceration  is  not  always  the  one  which  I  have  de- 
scribed ;  for  example,  it  may  be  formed  on  a  level  with  the 
tracheal  incision.  Around  it  are  found  the  same  lesions ;  the 
cartilages  are  worn  off,  eroded  and  jagged  on  their  cut  surface. 
In  one  case  they  were  destroyed  in  the  anterior  third  of  their 
circumference.  This  class  of  ulcerations  coincide  nearly  al- 
ways with  those  of  the  inferior  part.  Others,  finally,  are  found 
beyond  reach  of  the  canula  and  just  within  the  larynx ;  this 
is  what  may  be  seen  in  the  patient  of  whom  I  described  above 
the  laryngeal  ulcerations  affecting  the  vocal  cords.  The  ul- 
cerations of  the  trachea  always  coincide  with  other  lesions  of 
the  respiratory  passages.  In  twenty-three  autopsies  redness 
of  the  tracheal  mucous  membrane  is  described  fifteen  times, 
in  which  eleven  cases  of  broncho-pneumonia  are  mentioned. 
More  rarely  one  finds  pseudo-membranous  bronchitis,  pulmon- 
ary apoplexy,  oedema  of  the  glottis,  and  tubercularization.  It  is 
no  less  interesting  to  know  the  condition  of  the  wound   in   the 


PATHOLOGICAL    ANATOMY.  93 

integuments.     In  twenty-three  cases  of  tracheal  ulceration  the 
wound  was  attacked  with  : 

Gangrene,  1 1  times. 

Diphtheria,  2  times. 

Simple  ulceration,  2  times. 

Was  healthy,  /  times. 

Condition  not  noted,  i  time. 

The  frequency  of  gangrene  of  the  wound  is  striking;  the 
tracheal  ulceration  appears  to  be  frequently  only  the  extension 
of  the  necrotic  process.  The  loss  of  substance  of  the  mucous 
membranes  and  of  the  cartilages  may  be  followed,  after  cica- 
trization and  recovery,  by 

Strictures  of  the  Trachea. — They  are  the  consequences  of  ul- 
cerations (especially  of  those  located  on  the '  margins),  cauter- 
izations and  of  losses  of  substance  at  the  expense  of  the  carti- 
lages, caused  during  the  operation.  Their  site  varies  with  that 
of  the  ulceration  ;  in  one  case  cited  by  Blachez  it  was  found 
on  a  level  with  the  vocal  cords.  The  degree  of  narrowing  is 
not  very  marked,  at  least  in  the  few  cases  which  have  been  ob- 
sei'ved  in  autopsies. 

Polypus  of  the  Trachea. — N.  Gigon  of  Angouleme,  and  Ber- 
geron have  called  attention  ■  to  this  interesting  incident.  A 
communication  made  by  Krishaber  in  1874  to  the  Societe  de 
Chirurgie  was  the  occasion  of  discussion  in  this  society  as  well 
as  in  the  Societe  Medicale  des  hopitaux,  and  in  the  Societe 
de  Medecine  of  Paris.  Since  that  period  Bouchut  and  Calvet 
of  Castres  have  reported  examples.  I  myself  observed  one 
case  of  it  in  1871,  of  which  I  shall  give  later  a  brief  history. 
The  anatomical  examinations,  still  few,  do  not  permit  us  to  re- 
gard the  question  as  sufficiently  known.  These  tumors  as- 
sume the  form  of  vegetations,  fleshy  swellings,  pink,  round, 
soft  and  having  the  size  of  hemp  seeds  or  peas  ;  they  are  sessile, 
or  pedunculated,  and  floating,  isolated  or  multiple.  They  sensi- 
bly diminish  the  caliber  of  the  trachea.  Their  structure  is 
cellular.  The  histological  examination  has  been  made  in  a 
single  case,  that  by  Krishaber.  Ranvier  saw  in  this  tumor 
large  fleshy  nodules  analogous  to  those   which   are   developed 


94  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

around  drainage  tubes  or  even  a  papillary  polypus,  primarily 
clothed  with  epithelium,  but  which,  under  the  influence  of  trau- 
matic laryngitis,  may  have  assumed  the  characteristics  of 
fleshy  tumors.  According  to  Verneuil  this  would  be  in  reality 
a  papilloma.  The  location  or  seat  of  these  tumors  added  to 
the  discussion.  It  was  first  thought  that  they  were  implanted 
upon  the  cicatrix.  In  all  cases  in  which  autopsy  could  be 
made  they  were  found  appended  to  the  neighboring  mucous 
membrane.  Moreover,  their  likeness  to  fleshy  tumors,  and 
their  structure,  which,  in  the  only  case  of  known  examination, 
was  that  of  papilloma,  makes  their  derivation  probable  from 
mucous  membrane  rather  than  from  the  cicatrix. 

Rupture  of  the  Trachea. — Latour  reports  the  case  of  a  child 
in  which  a  rupture  of  the  first  two  rings  of  the  trachea  occurred 
during  a  violent  paroxysm  of  suffocation. 

IV.   The  Lungs. 

The  pulmonary  lesions  encountered  in  diphtheria  are  very 
various ;  some  of  them  are  so  frequent  as  to  be  regarded  as 
almost  the  necessary  accompaniment  of  the  disease ;  others 
are  more  rare.  They  have  been  mentioned  by  several  authors, 
among  whom  are  Barthez  and  Rilliet,  Hache,  Trousseau,  Mil- 
lard, etc.,  and  they  have  been  studied  with  care  by  Peter.  This 
learned  author  having  recourse  to  elaborate  statistics  has  proved 
the  frequency  of  these  morbid  conditions,  until  then  but  little 
known.  And  he  was  so  fortunate  as  to  show  that  they  were 
not  simple  complications  due  to  accident  or  to  external  influ- 
ence, but  were  especially  local  manifestations  of  the  same  gen- 
eral condition. 

I.  Simple  Bronchitis. — This  is  the  most  common  lesion  in 
diphtheria.  There  are  few  autopsies  following  croup  in  which 
it  is  absent,  whether  it  be  alone  or  accompanying  other  altera- 
tions. But,  however  frequent  it  may  be  in  croup,  it  is  not  ex- 
clusively confined  to  this  variety  of  diphtheria,  what  appears 
also  natural,  since  every  morbid  action  would  seem,  in  this  case, 
to  be  concentrated  upon  the  respiratory  apparatus.  I  have  seen 
it  in  fact  coincide  with  diphtheritic  angina  alone.     It  may  be 


PATHOLOGICAL    ANATOMY.  95 

limited  to  the  large  bronchi,  or  extend  to  the  small  bronchial 
divisions.  Its  intensity  is  in  proportion  to  its  extent.  But 
even  in  the  cases  in  which  it  becomes  generalized,  the  parts 
most  severely  attacked  are  the  last  invaded,  that  is,  the  most 
dependent.  The  inflammation  rarely  attacks  at  once  the  entire 
bronchial  surface,  it  descends  gradually  from  the  trachea  to  the 
bronchi  of  small  caliber.  In  the  majority  of  cases  it  preserves 
the  catarrhal  inflammatory  form ;  but  there  is  produced  at 
times,  upon  the  surface  of  the  air-tubes,  a  thick  muco-purulent 
exudation  which  may  be  quite  abundant.  This  it  is  which  fur- 
nishes an  expectoration  of  the  same  nature,  ordinarily  so  co- 
pious, which  is  often  observed  to  follow  tracheotomy.  I  have 
seen,  during  an  operation,  a  gush  of  muco-pus  escape  at  the 
moment  when  the  bistoury  opened  the  trachea. 

Simple  bronchitis  is  often  found  in  company  with  other  path- 
ological conditions  of  the  lungs,  viz.,  pseudo-membranous 
bronchitis,  broncho-pneumonia  and  pneumonia.  In  one  case 
the  redness  started  from  an  ulceration  of  the  trachea  situated 
below  the  incision,  and  extended  as  far  as  the  smallest  bron- 
chial ramifications ;  above  the  incision  the  mucous  membrane 
was  sound.  Should  the  bronchitis  and  the  ulceration  be  re- 
garded in  the  relation  of  cause  and  effect  ?  Without  ascribing 
too  much  importance  to  a  single  fact,  one  may  imagine  that  in 
a  disease  in  which  the  danger  of  bronchitis  is  constant,  inflam- 
mation produced  at  an  ulcerated  point  might  determine  a  gen- 
eral attack. 

Pseiido-Dicuibranoiis  Bro7ichitis. — From  the  catarrhal,  the 
bronchitis  becomes  exudative.  The  mucous  membrane  is 
strongly  injected,  red  or  dregs-of-wine  colored,  glossy  or  rough, 
and  on  its  surface  are  developed  false  membranes.  At  first  the 
exudate  is  thin,  pellucid,  friable  and  slightly  adherent ;  later  it 
assumes  a  dull  white  color  and  increases  in  consistence. 

At  a  period  still  more  advanced,  it  becomes  movable,  dense, 
resistant,  almost  cartilaginous,  and  of  a  greyish  brown.  On 
the  tenth  day  after  tracheotomy,  a  patient  ejected  from  the 
tracheal  wound  a  compact,  coreaceous  fragment  of  a  cylinder 
measuring   three   millimetres  in   thickness.     According  to  the 


96  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

duration  and  the  intensity  of  the  disease,  the  false  membranes 
occupy  a  limited  point  or  a  broad  extent  of  si'rface.  At  one 
time  spots  of  variable  size  are  scattered  in  the  bronchi ;  at  an- 
other there  are  fibrinous  cylinders  which  introduce  themselves 
into  the  bronchial  tubes.  These  cylinders  may  be  complete  or 
incomplete ;  in  the  large  bronchi  particularly,  they  are  hollow, 
their  circumference  presents  solutions  of  continuity.  It  is  in 
the  medium  sized  bronchi  that  the  best  cylindrical  appearance 
is  observed  ;  in  the  smallest,  the  central  canal  often  disappears 
and  only  solid  cylinders  are  seen,  or  even  little  white  shreds, 
quite  thin  and  narrow.  The  ribbon  form  is  not,  however,  the 
one  peculiar  to  the  small  bronchi,  it  is  observed  also  in  those 
of  large  or  medium  caliber ;  the  band  occupies  the  anterior 
part  of  the  tube,  and  divides,  and  at  the  same  time  becomes 
attenuated  and  ends  in  the  terminal  branches  by  a  kind  of  out- 
line. At  the  same  time  of  meeting  these  adherent  false  mem- 
branes, debris  is  seen  floating  or  free,  mixed  with  pus  or  muco- 
pus.  The  mucous  membrane  of  the  air-passage  is  inflamed 
throughout  its  extent,  even  at  those  places  where  no  false  mem- 
brane is  seen.  All  the  pulmonary  lesions  may  be  met  with  at 
the  same  time  as  pseudo-membranous  bronchitis.  But  there  is 
one  much  more  frequent  than  the  others,  almost  inevitable 
when  the  disease  has  continued  several  days ;  I  speak  of  bron- 
cho-pneumonia. Nevertheless,  pseudo-membranous  bronchitis 
appears  at  the  beginning  still  more  frequently  than  broncho- 
pneumonia. In  subjects  who  die  in  the  first  two  or  three  days 
bronchial  diphtheria  is  observed  more  frequently  ;  at  a  more 
advanced  period  these  two  conditions  are  found  united,  or  the 
broncho-pneumonia  exists  alone.  In  165  autopsies  in  which 
pseudo-membranous  bronchitis  appeared  it  coincided  with 
broncho-pneumonia  60  times,  with  pneumonia  17,  with  pleurisy 
8  times,  with  pulmonar}^  apoplexy  7  times,  and  simple  bron- 
chitis was  present  in  all  the  cases.  When  pseudo-membranous 
bronchitis  invades  the  small  bronchi,  one  fact  interesting  to 
note  is  often  produced.  The  fibrinous  cylinders  completely 
obstruct  the  bronchial  canaliculi  and  restore  the  pulmonary 
lobules,  situated   below  them,  to  the   foetal  condition,  just  as 


PATHOLOGICAL    ANATOMY. 


97 


broncho-pneumonia  does.  The  mechanism  is  the  same,  the 
lesion  is  identical ;  though  the  plug  is  fibrinous  in  one  case, 
and  purulent  in  the  other.  According  to  Peter,  bronchial 
diphtheria  will  be  met  with  most  frequently  on  the  fourth  day. 
The  abstract  which  I  have  made  from  my  observations  indi- 
cates the  fifth  day  as  that  on  which  the  extension  of  the  false 
membranes  to  the  bronchi  has  been  noted  the  most  frequently 
at  the  autopsy.  The  following  table  shows  how  these  cases 
are  proportioned : 


Date  of  Death. 
1st  day  of  the  disease 


2nd 

(<     (( 

3rd 

«     « 

4th 

((     (( 

5  th 

((     <( 

6th 

((     (< 

7th 

<(     <( 

8th 

<<     (< 

9th 

((     (( 

loth 

((     (( 

nth 

<(     (( 

1 2th 

<(     (( 

27th 

<(     (( 

No.  of  Cases. 

16 

21 
24 

37 
13 
10 

4 

9 
6 

3 
5 
I 


Total 


151 


The  result  of  this  table  is  to  show  that  pseudo-membranous 
bronchitis  is  most  frequently  observed  from  the  second  to  the 
sixth  day.  The  increase  is  rapid  from  the  second  to  the  fifth, 
there  it  is  abruptly  arrested  and  the  decrease  is  rapid  during 
the  following  days.  From  the  eighth  day  bronchial  diphtheria 
is  only  an  exception.  One  may  remark  that  while  pseudo- 
membranous bronchitis  may  be  anatomically  proved  at  a  per- 
iod so  near  the  commencement  of  the  disease,  its  onset  at  this 


98  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

Stage  has,  a  fortiori,  the  preference.  At  the  same  time  that 
diphtheria  prevails  in  the  bronchial  tubes  it  manifests  itself  in 
the  immense  majority  of  cases  in  other  organs,  particularly  in 
the  throat  and  larynx.  Twice,  however,  the  bronchial  tubes 
alone  were  attacked. 

3.  Bronchial  Pneumonia. — All  forms  and  all  degrees  of 
bronchial  pneumonia,  from  atelectasis  and  splenization  to  pur- 
ulent granules  and  pulmonary  vacuoles,  are  met  with  in  diph- 
theria. These  lesions  present  no  peculiarity  except  their  ex- 
tremely frequent  coincidence  with  this  disease,  but  in  them- 
selves there  is  nothin^"  special ;  their  description  agrees  en- 
tirely with  that  of  broncho-pneumonia  in  general,  which  I  need 
not  give  here.  Of  all  the  manifestations  of  diphtheria  pseudo- 
membranous laryngitis,  which  accompanies  bronchial  pneu- 
monia, is  the  most  frequent.  In  121  cases  of  broncho-pneu- 
monia found  at  autopsy,  in  subjects  attacked  with  diphtheria, 
119  were  coincident  with  pseudo-membranous  laryngitis.  In 
one  of  the  other  patients,  the  diphtheria  occupied  the  pharynx 
only,  while  in  the  second  it  was  limited  to  the  nasal  fossae. 
Next  in  order  of  frequence  comes  pseudo-membranous  bron- 
chitis. In  121  cases  of  broncho-pneumonia,  60  co-existed 
with  bronchial  diphtheria.  Other  localizations  of  diphtheria 
are  encountered  quite  frequently  with  broncho-pneumonia,  but 
almost  never  alone.  As  one  of  the  above  statements  proves, 
they  are  nearly  always  associated  with  laryngeal  diphtheria. 
Other  pulmonary  lesions  are  observed  concurrently  with 
broncho-pneumonia,  but  more  rarely ;  they  are  simple  bron- 
chitis, pneumonia,  pleurisy  and,  speaking  generally,  nearly  all 
the  anatomical  alterations  which  may  attack  the  lungs.  It  is 
particularly  during  the  first  few  days  that  bronchi-pneumonia, 
as  shown  by  autopsy,  exists  ;  in  some  cases,  however,  it  has 
been  found  at  a  more  remote  period.  The  following  table 
will  indicate  at  what  period  it  has  been  discovered  in  121  au- 
topsies: 


PATHOLOGICAL   ANATOMY.  99 

Date  of  Death.  No.  of  Cases. 

1st  day  of  diphtheria      -  -  -  -  2 

2nd   "     "           "  -  -  -  -  12 

3rd    "     "           "  -  -  -  -  II 

4th    "     "           «  -  -  -  -  15 

5th    "     "           «  -  -  -  -  19 

6th    "     "           «  -  -  -  -  14 

7th    •'     "           "  -  -  -  -  5 

8th    "     "           «  -  -  -  -  6 

9th    "     "           "  -  _  -  .  7 

lOth    "     "           "  -  -  -  -  7 

nth    "     "           "  -  -  -  -  I 

I2th    "     "           «.  -  -  -  -  4 

13th    "     "           «  -  .  -  -  5 

14th    "     "           "  -  -  -  -  I 

15th    "     "           «  .  .  ...  I 

i6th    "     "           «  -  .  .  -  I 

19th    "     "           «'  -  .  _  -  2 

20th    "     «           «  .  -  .  _  I 

23d     "     "           "  -  -  -  .  3 

27th,  30th,  31st  and  41st,  each  i  -  -  -  4 


Total  -  -  -  -  -  121 

From  this  table  one  important  fact  becomes  conspicuous, 
viz.,  the  great  frequency  of  broncho-pneumonia  in  the  early 
days  of  the  disease.  Peter  had  already  insisted  upon  this 
point  in  his  remarkable  work;  he  showed  that  pulmonary 
lesions  could  be  proved  anatomically  the  third  day.  By  prov- 
ing its  presence  from  the  second  day,  and  even  from  the  first, 
the  above  figures  demonstrate  positively  that  it  is  not  absolute- 
ly dependent  upon  tracheotomy,  but  that  it  is  produced  spon- 
taneously, as  simple  or  as  pseudo-membranous  bronchitis.  One 
may  still  more  fully  convince  himself  of  this  by  studying  the 
following  table,  in  which  is  set  forth  the  interval  which  has 
separated  tracheotomy  from  the  verification  of  the  broncho- 
pneumonia at  the  autopsy: 


lOO 


DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 


Date  of  Death 

1st 

day  of  the 

tracheotomy 

2nd 

" 

(      <( 

<< 

3rd 

(( 

((      (( 

(I      ^ 

4th 

(( 

((      (( 

<i      _ 

5th 

(( 

(( 

ti      _ 

6th 

(( 

(      (( 

(<      _ 

7th 

<t 

(      (( 

«      _ 

8th 

It 

(      <( 

ft      _ 

9th 

ti 

(      <( 

(( 

nth 

li 

(      « 

(t      _ 

13th 

(( 

(      <( 

(I      _ 

15  th 

it 

(      (. 

(( 

1 8th 

((     ( 

(      (< 

«      _ 

26th 

<(     ( 

(      (( 

<c          _ 

27th 

(<     < 

(      (( 

11        _ 

No.  of  Cases. 
20 
13 

6 
6 

4 

3 
2 
2 
I 
2 
I 
I 
I 
I 
I 


Total 


64 


The  results  are  identical.  The  maximum  coincides  with  the 
same  day  as  the  tracheotomy.  It  is  probable  that  at  least  the 
greater  part  of  these  cases  of  broncho-pneumonia  existed  be- 
fore the  operation.  The  second  day  they  are  still  quite  fre- 
quent, the  process  scarcely  diminished.  Then  it  rapidly  dimin- 
ishes on  the  third  day  as  we  depart  from  the  onset,  and 
the  violence  of  the  first  shock  diminishes.  Moreover, 
croup  cases,  not  operated  on,  furnish  their  share  of  bron- 
cho-pneumonia. In  121  autopsies  of  broncho-pneumonia 
21  were  in  cases  of  croup  without  tracheotomy.  Finally,  one 
case  of  diphtheritic  angina,  and  one  of  pseudo-membranous 
coryza,  both  exempt  from  other  localizations  of  diphtheria, 
were  accompanied  with  broncho-pneumonia,  recognized  at  the 
autopsy.    • 

4th.  Puhnonary  Congestion. — This  is  another  of  the  frequent 
complications  of  diphtheria,  whatever  may  be  the  localization 
of  this  latter.  It  occupies  one  only  of  the  lungs  or  both  or- 
gans simultaneously.     Its   seat  of  predilection   is  the   base   of 


PATHOLOGICAL    ANATOMY.  lOI 

the  posterior  border.  Its  color  is  red,  or  dregs-of-tvine,  or 
nearly  black.  I  do  not  insist  upon  its  other  anatomical  char- 
acteristics which  are  not  peculiar  to  diphtheria.  They  most 
frequently  coincide  with  diphtheria  of  the  larynx,  bronchitis, 
and  with  other  pulmonary  lesions,  such  as  simple  bronchitis, 
bronchial  pneumonia,  and  pneumonia,  pulmonary  apoplexy, 
oedema  of  the  lungs  and  pleurisy.  In  those  cases  it  corre- 
sponds with  the  intensity  of  the  respiratory  embarrassment. 
When  asphyxia  has  arisen  to  a  sufficient  degree  the  lung  be- 
comes engorged  with  dark  blood.  Sometimes  this  exists  to 
the  exclusion  of  every  other  pulmonary  alteration.  This  con- 
dition is  met  with  as  well  in  the  autopsies  of  diphtheria  as  in 
those  of  subjects  dead  of  infectious  diseases  of  diverse  nature. 
Its  frequency  and  intensity  are  in  proportion  to  the  preponder- 
ance of  the  infectious  element.  Finally,  in  certain  cases  every 
trace  of  false  membrane  has  disappeared,  but  the  diphtheria 
has  left  behind  it  a  general  paralysis  which  has  reached  the 
respiratory  muscles.  The  dyspnoea  which  results  from  this 
condition  again  produces  pulmonary  congestion. 

5.  Pneumonia. — Less  frequent  than  the  preceding  lesions, 
hepatization  of  the  pulmonary  parenchyma  is  not,  however, 
so  rare  as  it  seems  at  present  to  be  supposed.  Authors  are,  in 
fact,  much  more  interested  with  the  importance  of  broncho- 
pneumonia than  with  simple  pneumonia.  Barthez  and  Rilliet 
think  that  pneumonia  appears  always  in  the  lobular  form. 
Bouchut  speaks  of  the  latter  form  only.  Peter,  who  places 
pneumonia  and  broncho-pneumonia  in  the  same  chapter,  cites 
but  one  example  of  frank  hepatization.  Jules  Simon  places 
these  two  anatomical  conditions  together  among  the  pulmon- 
ary complications  of  croup.  Vogel  does  the  same.  I  find,  in 
my  observations,  48  cases  of  simple  (franche)  pneumonia,  of 
which  32  are  confirmed  by  autopsy.  In  these  anatomical 
forms,  pneumonia,  developed  under  the  influence  of  diphtheria, 
presents  nothing  special  to  note.  It  is  single  or  double,  and 
occupies  the  base  or  the  apex  of  the  lung.  It  remains  in  the 
second  degree  or  passes  to  gray  hepatization.  One  point,  how- 
ever, deserves  to  be  placed  in  evidence,  that  is  the  frequency, 


I02  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

in  diphtheria,  of  this  third  degree  of  pneumonia,  usually  so 
rare  in  children.  In  32  cases  of  pneumonia,  verified  by  autop- 
sy, I  found  9  cases  of  gray  hepatization.  The  following  table 
will  show  that  the  largest  number  of  these  cases  of  pneumon- 
ia have  been  found,  at  the  autopsy,  at  a  date  approximating 
the  attack : 

Date  of  Death.  No.  of  Cases. 

1st  day  of  diphtheria  -  -  -  -  o 

2nd    "     "  "  .  -  -  -  2 

3rd    "     "  "  -  -  -  -  5 

4th    "     "  "  -  -  -  -  2 

5th    "     "  "  .  -  _  .  7 

After  this   one  a   day  only  except  the  13th  day,  on  which 
there  were  2. 
Date  of  death  not  known  -  -  -  -  6 

The  interval  which  separates  tracheotomy  from  the  anatom- 
ical verification  of  the  pneumonia  no  longer  fails  to  be  of  in- 
terest. As  in  broncho-pneumonia,  so  here  the  greatest  number 
coincides  with  the  first  and  second  days  of  the  operation; 
there  is,  therefore,  reason  to  adopt  tlie  same  conclusions  and 
to  admit  that  the  complications,  far  from  resulting  from  trache- 
otomy, as  a  sole  cause,  are  principally  due  to  the  original  in- 
tensity of  the  disease.     The  table  below  proves  what  I  assert. 

Date  of  Death.  No.  of  Cases. 

1st  day  of  tracheotomy    -  -  -  -  8 

2nd    "     "  "  -  ...  5 

3rd    "     "  "  _  -             -             -  3 

4th    "     "  "  -  -             -             -  I 

5th    "     "  «  -  ...  3 

6th    "     "  "  -  -             -             -  I 

8th    "     "  "  -  -             -             -  2 

loth    "     "  "  -  -             -             -  I 

I2th    "     "  "  -  -             -             -  I 

i6th    "     "  "  ...  -  I 

51st     "     •'  «  .  -            -            .  I 

Total  -  -  -  ...  27 


PATHOLOGICAL    ANATOMY.  IO3 

We  may  still  add  that  pneumonia  did  not  destroy  solely  the 
operated  cases  of  croup.  The  five  remaining  cases  of  the  32 
autopsies  are  divided  as  follows : 

Croup  not  operated  -  -  _         '    -  4  cases 

Diphtheritic  angina  without  croup  -  _  i      " 

In  the  last  patient,  pneumonia  was  found  at  the  autopsy,  the 
fifth  day.  The  preceding  figures  are  conclusive  :  tracheotomy 
is  not  the  sole  cause  of  the  pneumonia  any  more  than  of  the 
other  pulmonary  inflammations. 

Of  all  the  diphtheritic  manifestations,  pseudo-membranous 
bronchitis  is  the  one  which  coincides  most  frequently  with 
pneumonia.  Respecting  the  pulmonary  inflammation,  pneu- 
monia may  be  circumscribed,  but  that  is  the  exception.  But 
how  shall  we  comprehend  the  origin  of  pneumonia  in  a  case 
of  diphtheria,  if  it  be  not  by  the  propagation  to  the  pulmonary 
parenchyma  of  the  bronchial  inflammation  so  common  in  this 
disease.  The  results  of  autopsies  justify  this  view  of  the  case; 
and  they  show  us  the  almost  constant  co-existence  of  pneu- 
monia with  intense  bronchitis,  purulent  or  not,  with  pseudo- 
membranous bronchitis  and  bronchial  pneumonia.  In  32  au- 
topsies pneumonia  was  found  : 

With  pseudo-membranous  bronchitis    -  -  16  times 

"      broncho-pneumonia  -  -  -  lO       " 

"     bronchitis  -  _  _  _  6       " 

In  three  of  these  patients  broncho  pneumonia  and  bronchial 
diphtheria  united,  were  concurrent  with  pneumonia.  In  eight 
of  the  observations  the  condition  of  the  air  passages  was  not 
noted.  We  see  how  frequent  the  cases  are  in  which  may  be 
comprehended  the  diff'erent  phases  of  the  inflammatory  action 
which  commences  in  bronchitis  and  ends  in  hepatization.  Other 
lesions  of  less  importance  are  also  observed  with  pneumonia ; 
they  are  pleurisy,  pulmonary  oedema  and  pulmonary  apoplexy. 

6th.  Pleurisy. — Still  less  frequent  than  pneumonia,  this  takes 
a  lower  rank  among  the  thoracic  complications  of  diphtheria. 
Peter  is  the  only  author  who  mentions  it,  and  he  found  9  cases 


I04  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

in  121  autopsies.  I  have  met  with  it  twenty  times,  sometimes 
single,  sometimes  double.  It  is  characterized  in  the  greater 
number  of  cases  by  a  severe  effusion,  and  sometimes  by  ad- 
hesions.    In  one  case  the  liquid  was  purulent. 

Eleven  of  the  twenty  cases  occurred  from  the  third  to  the 
ninth  day  inclusive. 

The  interval  in  relation  to  the  tracheotomy  is  given  in  the 
following  table : 

Date  of  Death.  No.  of  Cases. 

1st  day  of  the  tracheotomy  -  -  -  5 

2nd  "     "      "  «  -  -  .  2 

4th    "     "      «  "  .  -  -  -  I 

5th    "     "      «  «  -  -  -  3 

6th    "     "     "  "  -  -  -  I 

nth,  I2th  and  13th,  i  each,  "  -  "  3 


Total  -  -  _  -  -  15 

[There  was  well-marked  pleuro-pneumonia.  in  one  of  my 
recovered  cases  of  tracheotomy.] 

The  results  furnished  by  these  statements  do  not  differ  sen- 
sibly from  those  respecting  pneumonia  and  broncho-pneumon- 
ia ;  it  is  also  in  the  first  days  that  the  highest  numbers  are 
found.  All  the  forms  of  diphtheria,  but  particularly  croup  and 
pseudo-membranous  bronchitis,  are  to  be  found  with  pleurisy; 
with  these  two  principal  forms  are  associated,  more  rarely,  an- 
gina, coryza,  and  others  which  are  never  found  isolated.  Pleur- 
isy always  accompanies  some  other  pulmonary  phlegmasia. 
We  may  in  fact  consider  it  as  the  final  termination  of  the  in- 
flammatory process,  which,  beginning  at  the  bronchial  mucous 
membrane,  is  propagated  to  the  pulmonary  parenchyma. 

Most  frequently  this  process  stops  in  its  course,  a  circum- 
stance which  explains  the  relative  infrequency  of  pleurisy.  In 
20  autopsies  pleurisy  co-existed : 

With  broncho-pneumonia  -  -  -  13  times 

"     pseudo-membranous  bronchitis       -  -  9      " 

"     pneumonia  -  -  -  -  4     " 

"     bronchitis    -  -  -  -  .  2      " 


PATHOLOGICAL    ANATOMY.  IO5 

In  seven  of  these  cases  broncho-pneumonia  and  pseudo- 
membranous bronchitis  existed  simultaneously.  In  nearly  all, 
several  of  these  lesions  were  united.  That  which  we  found 
most  frequent  is  broncho-pneumonia ;  that  it  is  which  connects 
the  bronchitis  and  the  pleurisy  and  directs  the  inflammation  to 
the  pleura. 

7th.  Pulmonary  Emphysema. — This  is  one  of  the  most  common 
complications  of  diphtheria,  but  especially  that   of  the  air-pas- 
sages.    There  is  scarcely  an  autopsy  after  croup  in  which  alve- 
olar dilation  is   not  found.     This  fact  has  attracted  the   atten- 
tion of  observers.     Barthez  and   Rilliet   have   emphasized   the 
extreme  frequency  of  emphysema  in  croup.     Roger,  Peter  and 
Simon  have  observed  the  same  results.  My  researches  confirm 
in  every  particular  those  of  the  above  authors.  In  all  the  cases 
of  croup,  emphysema,  in  all  degrees,  is  found  and  in  all  forms. 
Most  frequently  it  is  vesicular,  but  it   may  be   inter-lobar  and 
sub-pleural.     In  some  cases,  finally,  it  reaches  the  mediastinum 
and  the  sub-cutaneous  cellular  tissue.     It  usually  occupies  the 
anterior  border  and  the  apex  of  the  lungs,  and  thence  extends 
to  the  anterior  surfaces.     The  difficulty  with  which  the  air  en- 
ters the  chest,  and  the  relative  facility   with   which   it   escapes 
does  not  allow  of  the  admission   that  the  emphysema  is   pro- 
duced directly  by  excess  of  intra-alveolar  pressure   in   inspira- 
tion and  expiration.     On  the  contrary,  everything  tends  to  the 
belief  that  it  pertains  to  the  class  of  compensatory  emphysema. 
In  fact,  as  Gairdner  has  shown,  whenever  certain  parts  of  the 
lungs  become  impermeable  to  air,  and  consequently  retract,  it 
happens  that   the    thorax,  continuing   or   even    increasing  its 
movements  of  amplification,  the  sound  parts,  compelled  to   fill 
the  vacuum  left  by  the  first,  dilate  energetically.      If  this  con- 
dition continues  a  certain  time,  in   the   least   degree,  the   vesi- 
cules  which  are  forcibly  dilated  return  no  longer  to  their  form- 
er condition,  and  emphysema  is  produced.     This  is  why  alve- 
olar dilatation  is  so  often  encountered  as   a  sequence  of  pneu- 
monia, chronic  bronchitis  and  of  all  the  pulmonary   diseases. 
Barthez  and  Rilliet  have  mentioned  its  frequency  in  broncho- 
pneumonia.    The    pulmonary    lesions    so    frequent    in    croup, 


106  niPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

from  simple  bronchitis  and  pseudo-membranous  bronchitis  to 
gangrene,  are  they  not  all-powerful  predisposing  conditions  to 
its  production  ?  When  it  becomes  general  it  arises  from  trau- 
matic causes,  and  is  frequently  produced  by  inflation  of  the 
lungs  without  care,  through  the  wound,  in  case  of  apparent 
death  during  the  operation.  The  effort  exerted  in  this  way 
causes  also  rupture  of  the  pulmonary  vesicles,  and  consequent- 
ly sub-pleural  emphysema.  These  are  really  accidents  result- 
ing from  the  operation. 

8th.  Pulmonary  Apoplexy. — Pulmonary  apoplexy  was  pointed 
out  by  Millard,  then  by  Peter  and  by  Bouchut.  It  is  one  of 
the  more  rare  complications  of  diphtheria,  and  I  have  collected 
eighteen  observations.  It  is  located  particularly  at  the  poster- 
ior part  and  at  the  base  of  the  lungs.  At  one  time  it  presents 
itself  under  the  form  of  sub-pleural  ecchymosis,  attacking 
sometimes  a  part  the  size  of  a  dime,  but  ordinarily  smaller, 
resembling  petichiae,  or  presenting  only  a  point  of  quite  lim- 
ited extent.  At  another  time  it  is  a  true  infarctus,  or  apopletic 
foci  are  disseminated  in  the  pulmonary  structure.  Most  fre- 
quently these  two  forms  are  associated ;  the  spots  may  exist 
alone ;  the  infarctions  are  rarely  met  with  without  the  spots. 
The  composition  of  these  foci  is  purely  hematic.  Still,  in  the 
case  reported  by  Bouchut  some  of  the  dark  foci  enclosed  in 
their  centres  a  grayish  portion  of  purulent  infiltration,  some- 
times a  real  sac  containing  pus  ;  others  were  converted  entirely 
into  abscesses.  It  is  in  the  cases  of  croup  and  pseudo-mem- 
branous bronchitis,  in  which  asphyxia  predominates,  that  pul- 
monary apoplexy  is  found.  However,  I  have  shown  its  exist- 
ence in  a  patient  attacked  with  diphtheritic  angina  and  with 
coryza  without  laryngeal  or  bronchial  manifestations.  Besides, 
it  should  be  stated  that  it  appears  to  prefer  the  generalized 
«  diphtheria  of  the  infectious  form,  accompanied  with  consider- 
able adenitis  and  albuminuria.  Other  pulmonary  complications 
exist  at  the  same  time,  viz.,  broncho-pneumonia,  pneumonia, 
pulmonary  congestion  and  bronchitis.  In  one  case  there  was 
observed  at  the  same  time  with  it  a  granular  condition  (sable) 
of  the  cerebral    substance,   and   considerable    engorgement   of 


PATHOLOGICAL    ANATOMY.  IO7 

dark  blood  in  the  sinuses  of  the  dura  mater.     Finally,  I  have 
seen  it  co-exist  with  general  diphtlieritic  paralysis  extending 
to  the  respiratory  muscles,  from  which  the  patient  succumbed, 
after  the  false  membranes  had  disappeared,  and  in  the  absence 
of  other  pulmonary  complications.     Hence,  apoplexy  in  diph- 
theria appears  to  proceed  from  two  causes,  viz.,  asphyxia  and 
infection.  The  patho-genetic  role  of  asphyxia  is  known.    Now, 
if  there  is  a  disease  capable  of  producing  asphyxia,  it  is  croup, 
especially  and  particularly  that  form  of  it   which   accompanies 
bronchial  diphtheria  or  broncho-pneumonia.     All  the   cases  of 
apoplexy,  except  one,  coincided  with  croup.     The  influence  of 
asphyxia  indicated  by  theory  is  therefore  verified  anatomically 
and  appears  indisputable.     But  this  is  not  the   sole   cause  ;  we 
find  proof  of  it  in  observation  which  shows  us  apoplexy  arising 
in  a  case   of  diphtheria  limited  to  the  throat  and  nasal  fossae 
and  exempt  from  other  respiratory  disturbances.   It  is  averred, 
on  the  other  hand,  that  pulmonary  apoplexy  has  a  tendency  to 
form  in  grave  fevers,  in  black   small-pox,   and  in  haemorrhagic 
scarlatina  and  measles,  in  typhoid  fever,  in  purulent  infection 
and  in  anaemia.     Diphtheria  by  its  infectious   character  being 
assimilable  to  these  different  conditions,  one  may  admit  that  it 
may,  by   this   sole   cause,   favor  the  production  of  pulmonary 
apoplexy.     In  the  case   of  general  diphtheritic   paralysis,  the 
cause  of  death  was  asphyxia  from  the  immobility  of  the  res- 
piratory muscles ;  there  is  no  necessity  to  examine  whether  or 
not  one  has  had  to  do  with  a  case  of  pulmonary  heemorrhages 
which  arise   under  the  influence   of  the  nervous  system,  such 
as  were  observed  clinically  by  Barthez  and   Rilliet,  as  well  as 
by  Barrier,  and  experimentally  by  Claude  Bernard  and   Brown 
Sequard.     Another  cause  has   recently   been   referred   to    by 
Bouchut   and   Labadie  Lagrave,  I  mean  capillary  emboli  and 
interlobular  thrombosis.     The  role  of  emboli  in  the  production 
of  pulmonary  apoplexy  is  too  well  known  to  require  discussion. 
But  these  two  learned  authors,  having  admitted  the  frequency 
of    endocarditis  and   cardiac    thrombosis   in   diphtheria,  were 
obliged,  very  naturally,  to   suppose  that  pulmonary  embolism 
was  frequent  in  this  malady.     One  will  see  later  what  restric- 


I08  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

tions  must  be  placed  upon  these  assertions,  and  how  much  the 
importance  of  endocarditis  and  thrombosis  in  diphtheria  should 
be  diminished.  Moreover,  in  some  of  the  observations  which 
Labadie  Lagrave  presented  as  examples  of  infarctus  by  em- 
bolism or  by  thrombosis,  there  were  found  in  the  heart  only 
the  clots  of  simple  coagulation. 

9,  Pulmonary  Gangrene. — Only  three  cases  of  this  condition 
have  been  described,  two  by  Garnier,  who  observed  them  in 
the  service  of  Barthez,  the  other  by  Callandreau  Dufresse.  I 
can,  on  my  part,  report  still  another  example.  In  three  of 
these  four  cases  the  gangrene  occupied  both  lungs.  In  all,  the 
seat  of  it  was  the  base.  It,  in  every  case,  presents  itself  in  the 
form  of  a  focus  (one  or  more)  which  was  in  one  case  accom- 
panied with  superficial  patches.  The  greenish  color  of  the  tis- 
sues reduced  to  a  detritus,  the  peculiar  odor  and  all  the  char- 
acteristics of  the  process  of  mortification,  correspond  to  the 
name.  The  lungs  were  engorged  with  a  dark,  fetid  liquid. 
The  conditions  under  which  pulmonary'  gangrene  is  produced 
are  not  the  same  in  all  cases.  Twice  it  occurred  in  a  case 
operated  upon  for  croup;  once  in  a  case  of  croup  not  operated, 
and  once  in  a  case  of  diphtheria  limited  to  the  throat.  Three 
times  in  four  there  was  broncho-pneumonia,  and  the  gangrene 
appeared  to  be  developed  by  the  increase  of  inflammation  of 
the  parts  already  diseased.  Angin?  without  croup  is  of  this 
number.  In  only  one  case  did  the  question  of  other  pulmon- 
ary lesions  not  arise,  but  the  report  of  the  autopsy  is  very  brief, 
and  perhaps  only  the  most  prominent  phenomenon  was  noted. 
In  three  cases  gangrene  occupied  other  organs.  In  the  two 
tracheotomized,  the  integumentary  wound  was  gangrenous ;  in 
the  patient  attacked  with  angina  without  croup  there  was  very 
extended  gangrene  of  the  uvula,  the  soft  palate  and  the  ton- 
sils. Diphtheria  was  primary  in  three  cases ;  in  the  fourth,  the 
one  by  Callandreau  Dufresse,  it  was  a  case  of  croup  tracheot- 
omized after  measles.  This  exanthema  being  quite  often  fol- 
lowed by  gangrene,  without  it  being  necessary  that  diphtheria 
should  intervene,  the  case  loses  much  of  its  importance  and 
may,  when  speaking  accurately,  be  excluded. 


PATHOLOGICAL    ANATOMY.  IO9 

10.  CEdenia. — This  accident  has  as  yet  been  httle  studied. 
Barthez  and  Rilliet,  however,  intimate  that  they  have  seen  sev- 
eral cases  of  oedema  of  the  lungs ;  and  they  attribute  them  to 
obstruction  of  circulation  and  to  violation  of  hematoses  re- 
sulting from  the  obstruction  to  the  passage  of  air  into  the 
lungs.  Fischer  reports  one  case  of  it  observed  at  the  clinic 
of  Traube.  In  no  other  case  is  oedem^  of  the  lungs  set  forth 
in  diphtheria.  I  have  met  several  examples  of  it.  The  infil- 
tration occupies  both  lungs,  especially  towards  the  bases  and 
to  a  variable  extent,  which  is  not  always  the  same  for  each 
lung.  The  cases  which  I  have  observed  are  divided  into  two 
categories.  In  those  of  the  first,  which  are  most  numerous, 
the  oedema  is  accompanied  with  extensive  and  serious  pulmon- 
ary lesions,  such  as  broncho-pneumonia,  pseudo-membranous 
bronchitis,  pneumonia  and  pulmonary  congestion.  Several  of 
these  pathological  conditions  are  nearly  always  combined. 
CEdema  appears,  therefore,  very  clearly  to  proceed  from  the 
embarrassment  which  is  produced  in  the  circulation  of  the 
lung.  In  those  of  the  second  category  the  pulmonary  lesions 
are  much  less  important ;  sometimes  they  fail  entirely,  but 
oedema  exists  in  other  organs,  and  the  existence  of  renal  alter- 
ations is  observed.  Twice  oedema  of  the  glottis  coincided 
with  that  of  the  lung,  in  subjects  in  which  the  diphtheria  had 
presented  an  infectious  character,  very  marked,  and  which, 
among  other  symptoms,  had  presented  albuminuria.  Cases  of 
this  categoiy  seem  therefore  principally  connected  with  altera- 
tions of  the  blood. 

Section  5.     Mediastinum. 

This  region  is  sometimes  the  seat  of  abscesses  which  nearly 
always  have  for  their  cause  operation-accidents  arising  during 
tracheotomy.  Abscess  of  the  mediastinum  has  been  brought  to 
notice  by  Millard,  Crequy,  Pellitier  of  Chambure,  and  Boeckel, 
and  I  have  reported  ten  cases  of  it.  It  is  not  my  intention  to 
give  a  complete  description  of  the  anatomical  lesions  which 
characterize  abscesses  of  the  mediastinum,  I  shall  only  indicate 
the  varieties  which  have  been  encountered,  succeeding  trache- 


no  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

otomy.  The  pus  was  sometimes  collected  into  a  purulent  focus 
of  which,  the  dimensions  attained  the  size  of  an  egg;  in 
other  cases  there  were  purulent  tracks,  starting  from  the  tegu- 
mentary  wound,  penetrating  more  or  less  deeply  into  the  med- 
iastinum, or  simple  purulent  infiltration  of  this  region.  In  one 
case  the  pus  was  not  yet  apparent,  and  there  was  found  only  a 
sero-gelatinous  streak,  Vhich  followed  the  same  direction. 
Suppuration  is  met  with  in  all  parts  of  this  region,  viz.,  on  the 
anterior  surface  of  the  trachea,  on  its  posterior  part,  and  in  the 
planes  which  separate  it  from  the  oesophagus ;  the  latter  itself 
might  be  surrounded  by  this  suppurated  centre.  In  all  the 
autopsies  the  lesions  started  from  the  wound  in  the  integument. 
I  have  seen  the  pus-center  communicate,  by  a  perforation  of 
the  posterior  tracheal  wall,  with  a  second  collection  seated 
under  the  laryngeal  mucous  membrane.  The  relations  of  the 
abscess  with  important  organs  of  the  mediastinum  may  par- 
ticipate in  producing  the  phenomena  of  dyspnoea,  which  some- 
times accompanies  the  development  of  the  swelling.  In  two 
cases  the  sternum  was  denuded  and  there  was  commencing  ne- 
crosis. Emphysema  of  the  mediastinum,  of  the  neighboring 
sub-cutaneous  tissue,  and  of  the  lung,  frequently  coincides  with 
the  abscess. 

Section  6.     Circulatory  Apparatus. 

For  a  long  time  disturbances  of  the  circulation  have  been 
observed  in  patients  attacked  with  diphtheria.  The  alterations 
so  remarkable,  of  the  blood,  the  existence  of  clots  in  the  cav- 
ities of  the  heart,  and  cases  of  sudden  death,  have  attracted 
the  attention  of  observers.  It  is  particularly  within  the  last 
fourteen  years  that  these  questions  have  been  studied.  The 
progress  made  in  cardiac  pathology,  the  discovery  of  endocar- 
ditis in  fevers  and  in  septic  diseases,  have  inspired  some  able 
authors  with  the  thought  of  searching  for  endocarditis  in  diph- 
theria. The  results  reached  have  given  to  these  lesions  quite 
an  importance ;  but  they  were  not  long  in  being  refuted  by  an 
observer  whose  works  in  pathological  anatomy  have  justly  ac- 
quired an  authority  by  reason  of  the  precision  he  gave  to  them 


PATHOLOGICAL    ANATOMY.  1 1  I 

and  the  careful  guarding  to  which  he  submitted  them.  This 
part  of  the  pathological  anatomy  of  diphtheria,  being  as  yet 
little  known  and  still  contested,  I  shall  say  something  of  the 
principal  works  which  relate  to  it.  Richardson  pointed  out 
the  existence  of  fibrinous  concretions  in  the  right  heart  during 
the  course  of  diphtheria,  and  described  the  symptoms  which 
correspond  to  them.  Barry,  of  Tunbridge  Wells,  reports  three 
cases  of  clots  in  the  right  cavities.  Beau  relates  a  very  inter- 
esting observation  of  sudden  death  in  diphtheria,  which  he  at- 
tributes to  the  same  cause.  An  autopsy,  unfortunately,  could 
not  be  made.  John  Bridger  of  Coltenham  says  he  has  treated 
more  than  three  thou^nd  cases  of  diphtheria!  Among  the 
complications  which  he  has  encountered  figured  pleurisy,  peri- 
tonitis and  endocarditis.  In  many  autopsies  he  has  found  the 
mitral  valves  uneven,  red,  thickened,  especially  at  the  centre, 
by  an  interstitial  deposit.  He  has  observed  loi  cases  of  diph- 
theritic endocarditis.  Meigs  publishes  three  observations  of 
cardiac  thrombosis  supervening  under  the  same  circumstances. 
There  were  found  in  both  cardiac  cavities  clots,  adherent,  dis- 
colored and  already  old.  In  one  case  this  verification  was 
made  on  the  twenty-first  day  of  the  disease.  Gerlier  analyzed 
several  observations  of  Beau,  Bergeron,  Meigs,  and  others  of 
his  own.  He  proved  the  existence  of  clots  in  the  heart  and 
sought  the  part  which  belongs  to  them  in  the  production  of 
sudden  death.  Beverly  Robinson  assigns  an  important  place 
to  cardiac  thrombosis;  it  is  a  frequent  complication  of  diph- 
theria and  a  very  common  cause  of  death.  The  polyp-forms 
of  clots  are  the  origin  of  fatal  accidents  and  not  their  results. 
Bouchut  and  Labadie  Lagrave  have  insisted  upon  the  great 
frequency  in  diphtheria  of  vegetative  endocarditis,  and  as  a 
sequence  cardiac  thrombosis  as  well  as  pulmonary  emboli. 

Callandreau  Dufresse  criticises  very  judiciously  Beverly  Rob- 
inson, Bouchut  and  Labadie  Lagrave,  and  shows  that  they  have 
accorded  a  place  too  important  to  cardiac  lesions.  Beau  Ver- 
deny  in  his  thesis  written  under  the  inspiration  of  Parrot 
speaks  in  the  same  way.  Parrot,  in  a  remarkable  memoir, 
combats  vigorously  the  work  of  Bouchut  and  Labadie  Lagrave. 


112  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

He  shows  that  these  authors  have  described  under  the  name 
of  endocarditis  lesions  of  an  entirely  different  nature.  To 
these  works  may  be  added  others  of  less  importance,  such  as 
those  of  Werner,  Smith,  Thompson,  RoUo  and  Winkler.  I  shall 
consider  in  order  the  different  parts  of  the  circulatory  apparatus. 

I.     Pericardium. 

The  alterations  of  this  serous  membrane  are  very  rare.  We 
find  it  sometimes  spotted  by  the  ecchymoses  which  are  found 
in  the  subjacent  connective  tissue.  It  is  ordinarily  in  the  cases 
in  which  asphyxia  has  played  an  important  part ;  and  then  we 
find  at  the  same  time  analogous  lesions  in  the  lungs.  We  find 
also  sometimes  small  yellowish  translucent  effusions  in  the  ser- 
ous cavity,  such  as  show  themselves  also  in  a  great  number  of 
subjects  dead  of  affections  quite  different.  But  as  to  pericar- 
ditis, strictly  speaking,  I  have  never  observed  it  at  the  autopsy. 

II.     The  Heart. 

The  cardiac  muscle  is  sometimes  altered.  It  is  dilated, 
gorged  with  blood  or  clots,  or  contracted.  In  some  cases  one 
perceives  in  its  substance  sanguineous  infiltrations  analogous  to 
those  which  are  seen  under  the  pericardium.  Asphyxia  is  suf- 
ficient cause  for  these  extravasations  without  it  being  necessary 
to  attribute  them,  as  Bouchut  and  Labadie  Lagrave  have  done, 
to  capillary  emboli.  The  most  common  lesion  is  fatty  degen- 
eration. It  is  observed  in  about  one-fifth  of  the  cases.  Gen- 
erally it  att?ccks  only  a  small  number  of  the  fibres  of  the  fasci- 
culi, but  it  may  invade  the  organ  to  a  large  extent,  or  entirely. 
In  the  latter  case  the  heart  is  pale,  its  color  approaches  that  of 
the  dead  leaf,  new  leather,  or  coffee  and  milk.  Its  consistency 
has  diminished,  it  is  softened,  preserves  the  imprint  of  the 
finger  or  becomes  friable  in  places.  The  microscope  reveals  in  it 
the  characteristics  of  granulo-fatty  degeneration,  viz.,  molecular 
and  fatty  granulation,  disappearance  of  the  transverse  striae  of  the 
fibrillze,  globules  or  larger  fat-globules.  Every  part  of  the 
cardiac  muscle  may  be  attacked ;  at  one  time  the  wall  exter- 
nally or  internally,  at  another  the  columnae  carneae.  The  origin 


I 


PATHOLOGICAL    ANATOMY.  II3 

of  these  nutritive  disturbances  appears  to  be  myocarditis.  It 
is  well  to  add  that  diphtheria  has  not  the  monopoly  of  these 
lesions ;  they  are  observed  in  all  infectious  diseases,  and  even 
in  diphtheria  they  are  found  in  cases  in  which  the  pulmonary 
lesions  are  sufficient  to  account  for  death. 

III.     The  Endocardium. 

Ecchymoses,  the  presence  of  which  under  the  pericardium 
has  been  pointed  out,  have  sometimes  been  observed  under  the 
endocardium.  Endocarditis,  but  lately  reserved  almost  ex- 
clusively to  articular  rheumatism,  has  been  recognized  in  a 
great  number  of  morbid  states.  Fevers  and  septic  diseases 
have,  however,  their  endocarditis.  It  was,  therefore,  quite  nat- 
ural to  seek  for  it  in  diphtheria.  That  iswhat  Bouchut  and  my 
friend  Labadie  Lagrave  did.  In  the  first  memoir  these  two 
authors  set  forth  that  they  encountered  vegetative  acute  endo- 
carditis 22  times  in  40.  In  the  second  Labadie  Lagrave,  sup- 
porting himself  by  22  autopsies,  confirmed  the  preceding  re- 
sults and  concluded  that  diphtheria,  whatever  may  be  its  local- 
zation  or  its  form,  nearly  always  entails,  though  not  constantly, 
an  acute  inflammation  of  the  endocardium,  and  in  particular  of 
that  part  of  the  serous  membrane  which  covers  the  auriculo- 
ventricular  valves.  This  able  work,  presented  and  executed 
with  ability,  has  not  convinced  me,  and  I  find  it  impossible  to 
accept  the  inferences  of  these  two  learned  authors.  Endocarditis 
is  in  fact  much  more  rare  than  they  admit.  Desirous  of  veri- 
fying data  so  new  and  interesting  I  judged  it  expedient  to  con- 
trol my  observations,  fearing  that  these  lesions  may  have  es- 
caped while  they  were  not  carefully  looked  for ;  I  have  applied 
myself  to  special  investigations.  In  65  autopsies  made  during 
the  last  two  years,  and  in  which  the  heart  was  scrupulously 
examined,  endocarditis  was  found  only  in  a  number  quite  in- 
significant. In  order  to  reach  an  understanding  it  is  necessary 
to  state  precisely  the  lesions  which  should  characterize  endo- 
carditis. Now,  what  characteristics  has  Labadie  Lagrave 
pointed  out  to  us?  They  are  :  i.  A  general  or  partial  redness 
circumscribing,  in    this    latter    case,  the    free    margins  of  the 


114  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

valves  by  a  zone  of  bright  red.  It  often  accompanies  vegeta- 
tions disposed  along  the  border.  In  all  the  cases,  with  one 
exception,  it  was  uniform  and  diffused.  Should  this  be  con- 
sidered as  proof  of  an  inflammatory  state  ?  Parrot  has  ans- 
wered the  question  in  the  negative ;  and  I  believe  he  is  entirely 
correct.  Really,  on  the  one  hand,  we  know  that  inflammatory 
redness  presents  among  its  characteristics  the  existence  of 
fine  vascular  arborizations.  On  the  other  hand,  diffuse  redness 
is  encountered,  in  a  great  number  of  autopsies,  following  dis- 
eases of  all  kinds,  but  especially  in  cases  in  which  the  form  of 
death,  from  asphyxia  or  otherwise,  has  been  the  cause  of  ac- 
cumulation of  blood  in  the  heart  during  the  last  moments  of 
life.  There  is,  therefore,  every  reason  to  believe  that  this  col- 
oring is  due  to  a  cadaveric  imbibition.  Moreover,  L.  Lagrave 
presents  an  objection  by  observing  that  this  origin  might  be 
admitted  in  a  certain  number  of  cases.  As  to  the  frequency 
of  this  coloring,  it  should  be  attributed  t&  the  action  of  the 
external  temperature,  the  autopsies  of  L.  Lagrave  having  been 
made  in  the  hottest  months  in  the  year,  viz.,  June,  July  and 
August  (Parrot).  2.  Mammillated  projections,  which  he  regarded 
as  vegetations  produced  by  endocarditis.  These  projections 
are  bright  red  at  their  base,  pink  in  the  middle,  and  often 
whitish  at  their  summit.  They  are  often,  also,  pearly,  glisten- 
ing and  fibrous,  and  occupy  the  upper  surface  of  the  valve 
some  millimeters  from  its  free  border,  forming  a  single  or 
double  festooned  band ;  more  rarely  they  extend  over  a  wider 
surface.  The  mitral  valves  are  their  ordinary  seat,  rarely  the 
tricuspid.  In  one  case  only  was  a  similar  projection  found  on 
an  aortic  valve.  These  primary  lesions  cause  the  coagulation 
of  the  fibrin  which  deposits  on  their  surface,  forming  as  many 
warty  stalactites.  The  valve  is  thickened,  tumefied,  and  ap- 
pears to  have  lost  its  delicacy  and  transparency.  To  make  a 
few  autopsies  of  children  is  sufficient  to  convince  one  of  the 
trifling  importance  of  these  little  projections.  They  are  quite 
common  and  are  met  with  after  diseases  of  the  most  diverse 
kind.  Hence  they  do  not  belong  exclusively  to  diphtheria. 
Are  they  inflammatory  products?  Can  they  characterize  endo- 


PATHOLOGICAL    ANATOMY,  II5 

carditis?  These  questions  have  been  answered  by  Parrot  in  a 
manner  irrefutable  that  these  recent  pretended  inflammatory- 
lesions  were  in  reality  the  products  of  the  fibrinous  transfor- 
mation of  the  little  haematoma  developed  upon  the  valves  dur- 
ing the  first  months  of  existence  and  perhaps  during  in- 
tra-uterine  life.  The  two  anatomical  peculiarities  offered 
as  proof  of  the  frequency  of  endocarditis  in  diphtheria  lose, 
therefore,  all  their  significance,  since  neither  of  them  belongs 
to  the  inflammatory  process.  Hence  it  results  that,  without 
denying  the  possibility  of  endocarditis,  one  should  consider  it 
as  much  less  common  than  those  authors  affirm  whose  opin- 
ions I  have  just  discussed. 

[Leyden  claims  to  have  discovered  lately  a  typical  myocar- 
ditis in  diphtheria.] 

IV.  The  Blood. 

Alterations  of  th©  blood  are  frequent  in  diphtheria.  They 
affect  its  color,  its  consistency  and  its  composition, 

A,  Color.  In  a  sufficiently  large  number  of  autopsies  the 
color  of  the  blood  seemed  modified.  Most  frequently  one 
finds  a  dark  coloring,  which  coincides  with  a  fluid  condition  of 
the  blood.  In  other  cases,  more  rare,  this  liquid  takes  a  brown 
tint  pointed  out  by  Millard ;  it  stains  the  fingers  like  sepia  and 
communicates  to  the  organs  impregnated  by  it  a  characteris- 
tic bistre  tint,  it  is  turbid  and  slightly  muddy;  the  coagula 
which  it  forms  have,  aside  from  their  softness,  a  kind  of  re- 
semblance to  over-cooked  jam  ;  finally,  the  arteries,  in  place 
of  being  empty,  contain  as  much  of  them  as  the  veins.  Peter 
has  also  pointed  out  this  alteration,  as  likewise  all  authors  who 
have  written  since  upon  croup  and  diphtheritic  angina.  Other 
tints  are  observed  ;  thus  the  blood  has  sometimes  the  appear- 
ance of  currant-jelly,  sometimes  that  of  water-ice  (wine  and 
water).  Finally,  I  have  seen  it  grayish  and  of  a  deeper  yellow 
than  the  sepia  tint.  These  varieties  belong  to  the  asphyxic 
and  infectious  forms  of  diphtheria.  Concerning  the  sepia 
blood,  Millard  and  Peter  have  emphasized  this  coincidence.  I 
can  but  affirm  their  assertions.     In  50  cases  in  which  I   have 


Il6  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

noted  the  alteration  of  the  blood,  the  sepia  tint  existed  20 
times.  In  this  number  it  was  coincident  17  times  with  the  in- 
fectious form  alone  ;  in  three  other  cases  the  malignity  was 
accompanied  with  asphyxia.  The  dark  and  fluid  state  of  the 
blood  was  present  28  times.  Of  these  28  cases,  20  were  co- 
incident with  infectious  diphtheria,  accompanied  or  not  with 
asphyxia.  In  8  others  asphyxia  had  predominated ;  I 
ought  to  cite  the  one  of  a  patient  who  succumbed  to  diph- 
theritic paralysis,  although  all  the  other  manifestations  of  the 
disease  had  disappeared.  The  chemical  and  histological  man- 
ifestations of  the  blood  under  the  circumstances  are  still  but 
little  known.  Nevertheless,  in  one  case  in  which  the  blood 
was  dark  and  diffluent  the  microscope  showed  that  the  blood 
globules  presented  nuclei  very  opaque,  dark,  varying  in  num- 
ber from  one  to  three  or  four. 

B.  Consistence.  This  may  be  diminished  or  increased.  When 
asphyxia  predominates  the  blood  is  nearfy  always  dark  and 
fluid  ;  when  infection  assumes  first  rank  the  blood  is  often  fluid, 
but  it  is  sometimes  thick,  as  occurs  in  the  sepia  tint.  In  other 
cases  the  blood  loses  its  homogeneity,  disintegrates,  remains 
fluid  in  certain  parts  and  coagulates  in  others.  It  is  in  the 
heart  and  in  the  large  vessels  that  the  coagulations  are  most 
frequently  found.  This  subject  having  attracted  a  lively  in- 
terest in  recent  times  and  given  rise  to  important  works,  I  shall 
devote  one  chapter  especially  to  it. 

Heart  Clots.  Cardiac  Thrombosis. — I  have  previously  men- 
tioned the  works  of  Werner,  Beau,  Richardson,  Gerlier, 
Smith,  Thompson,  Winkler,  Meigs,  John  Bridger,  Beverly 
Robinson,  Bouchut,  Labadie  Lagrave  and  Callandreau  Du- 
fresse,  upon  the  cardiac  concretions  in  diphtheria.  These 
authors,  after  having  pointed  out  the  presence  of  fibrinous 
clots  in  the  heart  of  subjects  dead  of  diphtheria,  have  attrib- 
uted to  these  concretions  an  important  role  in  the  mechanism 
of  sudden  death  occurring  during  the  course  of,  or  the 
convalescence  from,  this  disease.  These  coagula,  therefore, 
may  form  during  life  and  would  belong  to  thrombosis. 
Amono-  these  authors  Robinson  and  L.  Lagrave  have   insisted 


PATHOLOGICAL    ANATOMY.  11/ 

upon  the  importance  of  these  productions.  The  former  con- 
siders them  as  quite  frequent  and  as  often  causing  death.  I 
shall  have  to  make  some  exceptions.  The  capital  point  really 
is  to  know  whether  these  clots  are  indeed  formed  during  life. 
Before  expressing  myself  I  shall  present  the  results  which  au- 
topsies have  furnished  me.  I  shall  then  pass  in  review  the 
characteristics  by  which  one  recognizes,  according  to  the  most 
competent  authorities,  the  clots  formed  during  life.  We 
may  then  be  able  to  see  without  difficulty  whether  the  facts 
invoked  by  the  partisans  of  frequent  thrombosis  have  all  the 
value  that  they  have  been  disposed  to  give  them.  And  first, 
what  do  autopsies  declare?  The  clots  found  in  the  heart  of 
diphtheretic  subjects  are  of  tlirce  kinds,  some  are  purely  co- 
agulant; these  are  soft,  are  of  currant-jelly  color,  and  are 
mostly  lodged  in  the  right  cavity.  On  this  point  there  is  no 
disagreement;  all  consider  them  as  formed  after  death.  The 
second  s.xt  half-fibrinous  and  half-coagular ;  the  former  in  their 
antero-superior  part,  and  the  latter  in  their  postero-inferior 
part.  They  may  be  seen  especially  in  the  right  cavities,  and 
send  prolongations  to  a  greater  or  less  distance  into  the  ves- 
sels, hence,  their  polypoid  appearance.  These  are  also  pro- 
ducts formed  during  the  last  moments,  or  after  death.  Cornil 
and  Ranvier  explain  the  formation  in  the  following  manner: 
The  right  ventricle  is  distended  with  blood,  which  is  explained 
by  the  fact  that  dying  is  most  usually  accompanied  with  as- 
phyxia. The  auricles,  by  reason  of  their  feeble  contractibility, 
are  found  in  the  same  condition.  When  the  heart  ceases  to 
beat  the  blood  contained  in  its  cavities  coagulates  slowh^;  the 
red  globules,  which  are  the  heaviest,  sink  to  the  lowest  part, 
while  the  surface,  deprived  of  the  globules,  presents,  by  co- 
agulation, a  colorless,  fibrinous  mass.  This  is  the  explanation 
of  the  decoloration  of  the  clots  on  their  antero-superior  sur- 
face while  they  are  in  the  condition  of  a  coagulam  on  their 
postero-inferior  surface.  Cornil  and  Ranvier  refuse  to  admit 
that  these  clots  are  active,  that  is,  ibrmed  during  life.  Rind- 
fleisch  is  of  the  opinion  that  cardiac  thomboses  recognize  for 
their  cause  the  double  action  of  the  rugosity  of  the  walls  and 


Il8  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

the  slowness  of  the  circulation;  the  clots  which  result  there- 
from are  seldom  observed  on  the  surface  of  the  valves  even 
when  roughened;  and  they  are  small  and  never  attain  the  vol- 
ume of  those  large  fibrinous  coagula  whose  form  and  prolon- 
gations have  caused  them  to  be  designated  polypi,  and  which 
result  from  the  slowing  or  the  arrest  of  the  cardiac  circulation. 
We  find  in  the  observations  of  L.  Lagrave  several  of  these 
voluminous  clots  placed  in  the  list  of  thrombosis.  The  tliird 
are  purely  fibrinous.  They  vary  as  to  volume;  are  globular, 
entangled  by  their  base  in  the  tendons  of  the  valves  and  then 
become  thinner  so  as  to  send  prolongations  into  the  arteries 
or  auricles.  The  imprint  of  the  valves  then  remains  upon  their 
surface  in  the  form  of  a  constriction.  They  are  resistant  and 
sometimes  quite  hard.  Most  frequently  they  are  like  oede- 
mata ;  by  pressure  they  lose  quite  a  quantity  of  the  serum,  and 
diminish  perceptibly  in  volume.  Their  structure  is  fibrillar, 
but  not  granular.  All  parts  of  their  substance  appear  to  be  of 
the  same  age;  no  intimate  change  was  observed  in  it.  Such 
are  the  clots  that  I,  as  all  other  observers,  have  observed  in 
the  heart  of  subjects  dead  of  diphtheria.  We  find  them  not 
only  in  cases  in  which  death  has  occurred  from  the  heart,  but 
in  many  others  which  have  presented  no  cardiac  symptoms. 
The  autopsies  of  subjects  having  succumbed  from  lesions  of 
distant  organs,  the  brain,  for  example,  furnished  also  numer- 
ous specimens  of  it.  Let  us  now  examine  what  are  the  char- 
acteristics of  clots  formed  during  life.  Legroux,  my  lamented 
teacher,  has  given  them  in  an  excellent  work.  This  de- 
scription remains  classic.  Bucquoy  cites  them  in  numerous 
extracts.  Legroux  does  not  admit  that  the  masses  of  decol- 
ored fibrin  which  crowd  the  cavities  of  the  heart  are  the  re- 
sults of  morbid  action;  they  are  products  of  dying  (agonic);  it 
appears  to  him  that  these  fibrinous  concretions  could  only  be 
deposited  in  the  heart  with  difficulty  so  long  as  the  circubtion 
is  not  interrupted  for  a  certain  time.  The  signs  which  prove 
the  age  of  the  coagulum  are:  i.  The  condensation.  2.  The 
ashy  gray  color.  3.  Adherence  to  the  walls  of  the  heart  and 
to  the  valves,  adherence  which  need  not  be  confounded  with 


PATHOLOGICAL    ANATOMY.  II9 

entanglement  in  the  tendons  of  the  columns  carneae,  but  is 
formed  upon  an  uneven  surface,  altered  by  endocarditis. 
4.  The  structure  is  in  concentric  and  stratified  layers.  An 
anatomical  specimen  presented  to  the  Anatomical  Society  in 
November,  1875,  by  Balzer,  showed  the  complete  series  of 
these  essential  characteristics.  PouUet  and  Raynaud  give  as  a 
proof  of  vital  origin  the  constriction  produced  upon  the  clot 
by  the  valves.  That  is  not,  I  think,  a  proof  of  contraction  ex- 
erted by  the  walls  of  the  heart,  but  rather  the  result  of  the 
moulding  undergone  in  the  cavity  of  that  organ  and  in  the 
vessels.  In  fact,  when  death  occurs,  the  heart  being  in  diastole 
and  full  of  blood,  the  valves  present  no  resistance,  the  blood 
contained  in  the  heart  flows  into  the  large  vessels,  and  when 
the  mass  has  changed  into  fibrin  it  reproduces  the  contracted 
part  of  the  mould  which  corresponds  to  the  valvular  openings. 
The  arterial  prolongations  are  no  better  proof  of  formation 
during  life;  and  really  one  sees  the  concretions,  purely  coagu- 
lar,  sending  out  also  these  polypoid  ramifications.  Aside 
from  condensation  and  stratification  which  I  have  verified  in  a 
rather  small  number  of  cases,  the  other  characteristics  have 
failed  me.  Do  they  exist  in  the  clots  as  Meigs,  Robinson, 
and  L.  Lagrave  show  us  as  facts  of  thrombosis?  Not  posi- 
tively. Even  in  the  observations  of  L.  Lagrave,  who  believed 
in  the  frequence  of  endocarditis,  there  is  no  well-defined  ad- 
herence of  the  clots  to  the  internal  surface  of  the  heart.  A 
few  of  these  concretions  are  attached  to  the  walls  or  to  the 
columnae  carneae,  but  in  these  points  the  endocardium  is  not 
altered.  The  only  lesions  indicated  on  the  part  of  this  mem- 
brane are  the  nodules  or  mammillary  projections  ;  and  this  au- 
thor imputes  them  to  vegetative  endocarditis.  We  now  know  how 
to  value  this  interpretation.  I  shall  make  the  same  objections 
to  the  statements  of  Meigs.  It  is  not  without  interest  to  re- 
mark that  in  many  of  the  observations  made  by  these  authors 
grave  lesions  of  the  respiratory  apparatus  exist  at  the  same 
time  as  the  clots,  lesions  which  in  themselves  amply  suffice  to 
account  for  death.  One  may  still  add  that  these  coagulations 
have  been  encountered  in  a  large  number  of  cases  in  which 


I20  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

their  presence  was  in  no  way  revealed  during  life.  From  pre- 
vious considerations  it  follows  that  the  anatomical  facts  pre- 
sented in  cases  of  cardiac  thombosis,  as  clots  formed  during 
life  and  before  the  dying  (agonie),  lack  the  characteristics 
which  pertain  to  this  class  of  concretions,  and  that  concerning 
a  large  number  of  them  various  doubts  should  be  raised  re- 
specting the  period  of  their  formation.  We  shall  see  later 
whether  the  examination  of  the  symptoms  observed  during 
life  may  cause  us  to  retract  these  conclusions. 

Thrombi  in  the  Vessels. — The  heart  is  not  the  only  point  at 
which  clots  are  found.  In  several  parts  of  the  venous  system, 
and  particularly  in  the  sinuses  of  the  dura  mater,  they  may  be 
found,  but  exceptionally.  They  are  black,  coagular,  or  mixed, 
without  adherence  to  the  walls,  and  of  post-mortem  formation. 
Others  are  contained  in  the  pulmonary  artery  or  in  the  aorta. 
These  are  nearly  always  prolongations  from  clots  existing  in 
the  cavity  of  the  heart,  and  are  of  recent  origin.  Bouchutand 
L.  Lagrave  regard  capillary  emboli  and  interlobular  thrombi 
as  intervening  in  the  production  of  pulmonary  apoplexy.  They 
connect  also  the  former  with  the  small  bloody  effusions  which 
occur  under  the  skin.  Nothing  would  be  more  simple  if  we 
should  adopt  the  views  of  these  authors  on  the  frequence  of 
endocarditis  and  thrombosis.  But  we  have  been  able  to  con- 
vince ourselves  to  the  contrary  by  the  rarity  of  these  lesions. 
From  the  exceptional  character  of  pulmonary  emboli  in  diph- 
theria the  conclusion  must  be  so  much  the  clearer  that  upon 
this  special  point  the  observations  cited  in  its  support  are  no 
more  convincing  than  the  others. 

Composition. — The  alterations  of  the  blood  in  its  intimate 
composition  are  still  little  known.  Chemical  analyses  are 
wanting,  and,  consequently,  certain  data;  and  we  are  limited 
to  indicate  in  a  general  manner  the  modifications  which  the 
elements  of  this  fluid  undergo. 

The  plasma  or  the  globules  of  the  blood  may  be  affected. 

The  Plasma. — The  tendency  in  diphtheria  to  the  exudation 
of  fibrin,  often  in  abundance,  has  caused  many  authors  to 
suppose  that  this  disease  may  give  rise  to  an  increase   of  the 


PATHOLOGICAL    ANATOMY.  121 

fibrin  in  the  blood.  This  tl:eoretical  view  has,  as  a  conse- 
quence, been  follo\\ed  by  alterative  medication,  viz.,  mercuri- 
als, alkalines,  etc.  Nothing  is  more  fallacious,  however,  if,  in 
absence  of  direct  proof,  one  should  judge  by  analogy.  The 
blood  in  diphtheria  presents  that  condition  of  dyscrasia  desig- 
nated under  the  name  of  disintegrated  blood  [sang  dissotis), 
which  is  also  observed  in  certain  general  infectious  maladies 
which  have  to  it  a  strong  analogy,  viz.,  typhoid  fever,  the  grave 
fevers,  puerperal  conditions,  virulent  diseases,  etc.  The 
analysis  of  the  blood  in  these  diseases  made  by  Andral  and 
Gavarret  has  shown  a  remarkable  diminution  of  the  fibrin. 
The  similarity  in  the  external  aspect  of  the  blood  and  in  the 
general  characteristics  of  these  diseases  authorize  the  suppo- 
sition that,  far  from  producing  hypcrinosis,  diphtheria  produces, 
on  the  contray,  Jiypinosis.  The  formation  of  false  membranes 
is,  therefore,  no  evidence  of  an  excess  of  fibrin  in  the  blood, 
but  of  an  anomaly  in  the  conditions  which  maintain  the  plas- 
mine  and  other  albuminoid  materials  in  their  physiological 
fluidity  and  prevent  them  from  decomposing  by  reduction 
(dedoublement).  The  diphllieretic  poison  does  not  render  the 
blood  more  plastic,  it  disintegrates  it;  it  permits  the  plasmine 
to  become  reduced  and  to  allow  the  fibrin  and  albuminoid 
products  to  escape  in  the  form  of  false  membranes,  albumen, 
etc.  The  blood  globules  also  undergo  modifications.  Bou- 
chut  has  called  attention  to  leucocytosis.  In  fact  it  is  not  very 
rare  that  the  lecocytes  increase  in  considerable  proportion.  In 
several  of  the  observations  of  L.  Lagrave  we  find  these  bodies, 
which  in  the  normal  condition  scarcely  exceed  the  number  of 
three,  in  the  field  of  the  microscope,  rise  to  sixty.  I  have 
been  able  to  verify  these  results.  We  may  here  say  that  leu- 
cocytosis has  no  special  relation  to  diphtheria,  and  that  we 
meet  it  in  those  pathological  conditions  which  profoundly 
alter  the  organism.  The  red  globules  are  evidently  altered 
under  certain  circumstances,  notably  when  the  blood  assumes 
abnormal  colors.  Must  we  consider  in  sepia-blood  the  ab- 
normal increase  of  the  debris  of  the  red  globules,  a  debris 
sparse  in  the  normal  state,  but  considerablv  increased  by  the 


122  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

injurious  influence  of  the  diphtheritic  poison  which  rapidly 
produces  the  destruction  of  a  great  number  of  globules?  I 
have  above  reproduced  the  results  of  a  micrographic  exami- 
nation made  in  a  case  of  this  kind ;  researches  more  numer- 
ous, however,  will  be  necessary. 

Section  7.     Gemto-urinary  Apparatus. 

Kidneys. — Since  diphtheritic  albuminuria  was  pointed  out 
by  Wade,  of  Birmingham,  this  question  has  been  the  subject 
of  profound  study  by  several  authors.  But  it  is  in  a  theoret- 
ical and  semeiological  point  of  view,  rather  than  that  of  the 
anatomical  lesions,  that  these  works  have  been  conceived. 
Let  us  then  examine  the  renal  lesions  which  may  be  found  in 
diphtheria.  The  opinion  held  by  Lecorche  and  by  Lancere- 
aux  concerning  the  lesion  which  characterizes  albuminuria, 
and  of  that  of  diphtheria  in  particular,  is  that  it  is  superficial 
parenchymatous  nephritis.  This  anatomical  form  may  cer- 
tainly be  counted  among  the  most  frequent.  But  it  is  not  the 
only  one.  Others  sufficiently  numerous,  very  variable  and 
equal  in  extent  and  intensity,  are  frequently  observed.  Pass- 
ing in  review  these  pathological  conditions,  we  find,  first,  sim- 
ple hypercBmia,  which  frequently  is  accompanied  with  increase 
in  volume  of  the  organ.  The  congestion  may  occupy  the 
medullary  (tubular),  or  the  cortical  substance,  but  it  is  usually 
limited  to  the  former,  while  the  latter  has  become  pale.  These 
characteristics  are  very  apparent  on  section.  At  the  same 
time  the  external  surface  of  the  kidney  is  pink  and  is  sown 
with  red  points.  Sometimes  the  impression  is  sufficiently  in- 
tense to  produce  small  ecchymoses  on  a  plane  with  the  straight 
tubes  (Virchow).  When  to  the  hyperaemia  is  added  the  iji- 
flammatory  process  we  observe  desquamation  and  granular  de- 
generation (rarely  fatty)  of  the  epithelium  of  the  straight 
canaliculi.  The  cells  undergo  protein  infilitration,  which  ren- 
ders them  opaque,  but  they  may  recover  their  transparency 
under  the  influence  of  acetic  acid.  They  adhere  together  and 
coalesce  into  a  mass  which  moulds  itself  in  the  canaliculi,  and 
are  found  in  the  urine  in  the  form  of  epithelial  cyhnders.    The 


PATHOLOGICAL    ANATOMY.  I23 

process  may  cease  at  the  surface,  but  frequently  the  organ  is 
attacked  in  its  interior.  The  external  surface  of  the  kidney  is 
yellowish,  sprinkled  with  patches  of  a  lighter  yellow,  and 
section  shows  an  analogous  color  of  the  cortical  substance. 
The  latter  is  augmented  in  volume  and  sends  exuberant  pro- 
longations between  the  pyramids  which  strangulate  the  med- 
ullary substance.  This  latter  is  red,  in  consequence  of  the 
obstruction  which  the  compression  of  the  capillaries  of  the 
cortical  substance  offers  to  the  returning  circulation.  Some- 
times this  redness  is  scarcely  observed,  and  the  demarcation 
between  the  two  substances  is  almost  effaced.  The  consis- 
tency of  the  kidney  is  soft  and  friable.  We  find  at  this  period 
the  lesions  of  the  straight  tubes  signalized  in  the  above  form, 
but  one  observes  that  they  have  extended  to  the  tortuous  ca- 
naliculi  and  to  the  capsules  of  the  glomeruli.  By  virtue  of  a 
very  curious  anatomical  peculiarity  the  tortuous  canaliculi  are 
larger  than  the  loops  (anses)  of  Henle  which  follow  them.  It 
follows,  therefore,  as  Lecorche  observes,  that  the  epithelial  de- 
tritus, easily  expelled  in  the  form  of  cylinders  when  they  oc- 
cupy the  straight  canaliculi,  are  expelled  only  with  difficulty 
when  formed  in  the  tortuous  canaliculi ;  and  they  here  accu- 
mulate and  undergo  fatty  degeneration.  This  anatomical 
form  may  be  described  in  the  following  manner:  Epithelial 
hyperplasia,  cortical  anaemia  and  fatty  degeneration.  The 
transformation  is  more  or  less  important;  sometimes  it  forms 
only  a  few  small  yellow  patches,  more  frequently  they  are 
more  extended,  and  rarely  they  occupy  the  entire  organ. 
After  the  above  we  may  mention  the  amyloid  degeneration  of 
which  L.  Lagrave  cites  one  example.  We  know  that  this  pe- 
culiar transformation  has,  as  a  characteristic,  that  the  tissue 
thus  affected  acts  in  the  presence  of  the  iodo-sulphuric  reao-ent 
in  the  same  manner  as  does  starch.  Finally,  at  times  the  kid- 
ney presents  the  characters  of  simple  fatty  metamorphosis 
(steatose),  non-inflammatory.  In  these  cases  other  organs, 
the  liver  in  particular,  undergo  the  same  degeneration.  In 
these  diverse  pathological  states  the  renal  capsule  is  nearly 
always   healthy  and  not  adherent.     Another  very  important 


124  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

fact  deserves  to  be  mentioned,  that  is,  the  non-symmetry  of 
the  renal  alterations.  In  fact,  quite  frequently  one  kidney 
alone  is  diseased,  and  when  the  other  is  affected  it  is  to  a 
much  less  degree.  It  is  extremely  rare  that  both  organs  are 
attacked  with  the  same  intensity.  One  can  thus  explain  the 
rarity  of  oedema  and  cerebral  s)"mptoms  in  diphtheritic  albu- 
minuria, while  they  are  so  frequent  in  that  of  scarlatina.  In 
the  latter  both  kidneys  are  most  frequently  affected ;  now, 
however  superficial  may  be  the  lesions,  from  the  moment  that 
both  the  glands  are  out  of  condition  to  act,  the  elimination  of 
protein  material  is  suspended.  When  a  single  kidney  is  at- 
tacked, even  profoundly,  the  other  suffices  for  the  demands  of 
excretion.  The  other  organs  which  form  part  of  the  genito- 
urinary apparatus  are  only  very  exceptionally  the  seat  of  af- 
fections attributable  to  diphtheria.  Cases  of  diphtheria  of  the 
vesical  imicoiis  vievibrane  have  been  reported,  but  that  is  of 
German  diphtheria,  that  is  to  say,  the  word  is  diverted  from 
its  true  sense  to  be  applied  to  a  form  of  cystitis  which  we  call 
membranous,  and  which  has  no  relation  with  diphtheritic  in- 
fection. Behier  has  reported  some  cases  in  which  the  false 
membrane  developed  itself  in  lying-in  women  upon  the  sur- 
face of  the  uterus  at  the  place  of  the  placental  insertion. 
Trousseau  has  several  times  seen  diphtheria  of  the  vulvae  and 
of  the  vagina ;  he  has  also  observed  it  on  the  prepuce.  These 
pseudo-membranous  localizations  were  accompanied  with 
manifestations  of  the  same  nature  seated  on  other  regions.  I 
have  also  met  several  cases  of  it.  The  extension  of  false 
membranes  into  the  urethra  and  their  existence  on  the  glans, 
the  prepuce  and  scrotum,  have  been  pointed  out  by  several 
authors.  These  manifestations  are  very  rare.  Moreover,  they 
present  nothing  peculiar  to  themselves,  and  behave  like  all 
those  of  the  skin  or  mucous  membrane. 

Section  8.     The  Nervous  System. 

The  discovery  of  diphtheritic  paralysis  has  had  the  effect  of 
calling  attention  to  the  condition  of  the  nervous  system  in 
diphtheria,  and  especially  in  the  cases  of  paralysis.     At  pres- 


PATHOLOGICAL    ANATOMY.  12$ 

ent  the  results  obtainable  are  unsatisfactory,  and  we  must  wait 
till  new  researches  make  them  more  complete.     The  incom- 
pleteness is  explained  by  the  relative  rarity  of  autopsies  under 
circumstances  in  which  diphtheritic  paralysis  is  clearly  estab- 
lished.    Really  the  largest  number  of  patients  die  at  a  period 
soon   after  the   attack,    under   the   action    of  infection  or  as- 
phyxia, before  the  paralysis  has  been  able  to  develop  itself  in 
a  positive  manner.     Many  of  those  who  escape  these  dangers 
recover.     Those  who  succumb  from  the  action  of  paralysis  are 
few.     Of  this  number  how  many  autopsies  remain  unfinished 
because  of  the  time,  the  investigations  and  the  minute  prepa- 
rations that  they  require.     And  yet,  in  spite  of  the  use  of  the 
most  advanced  methods,  there  are  cases  in  which  the  results 
are  absolutely  negative.      Herman  Weber  publishes  the  report 
of  two  autopsies  of  diphtheritic  paralysis   in  which  the  brain 
and  spinal  cord,  examined  with  care  and  with  the  aid  of  the 
microscope,  presented  no  appreciable  alteration.      In  several 
of  the   observations  which   I  have  made  use  of  in  this  work, 
analogous   researches   made   with   the  greatest  care,  and  the 
highest  ability  by  D'Espine,  of  Geneva,  and  by  Gombault,  have 
reached  the  same  conclusions.     So  the  central  nervous  sys- 
tem appears,  at  the  present,  exempt.     I  do  not  speak  of  cere- 
bral congestion,  turgescence  of  the  sinuses  of  the  dura  mater, 
nor  of  meningeal  ecchymoses,  which  have  been  noted  several 
times ;   they  were  in  evident  relation  with  asphyxia,  which  had 
determined  death,  and  were  accompanied  with   other  lesions 
of  asphyxia,  such  as  pulmonary  apoplexy.     In  a  case  in  which 
a  patient  succumbed  to  convulsions  a  general  granular  con- 
dition of  the  white  substance  was  found ;   in  others,  in  which 
there  had  been  albuminuria,  oedema  and  cerebral  symptoms, 
I  was  able  to  verify  serous  effusions  of  the  meninges  and  ven- 
tricular oedema.     These  lesions  have  only  an  accessory  role  ; 
they  refer  to  grave  cerebral  symptoms  which    coincide  with 
paralysis.     The  peripheral  nervous  system  has  several  times 
presented  notable  alterations.     Charcot  and  Vulpian,   in  ex- 
amining the  soft  palate  (velum  pendulum  palati)  of  a  female 
dead  of  diphtheritic  angina  with  paralysis  of  this  organ,  found 


126  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY 

some  interesting  lesions.  A  certain  number  of  the  muscular 
fibres  had  become  fatty.  In  the  muscular  nerves,  certain  fibres 
were  composed  of  tubes  empty  of  medullary  matter.  Under 
the  neurilemma  granular  bodies,  with  or  without  nuclei,  were 
seen  at  certain  places.  Filaments  of  nerves  so  completely  de- 
generated were  rare;  in  the  larger  number  the  alteration  was 
only  partial;  and  then  they  were  composed  of  two  kinds 
of  tubes,  viz.,  one  containing  healthy  myeline ;  in  the  other 
this  latter  presented  a  sprinkling  of  fine  fatty  granules  either 
between  the  tubes  or  under  the  common  neurilemma ;  lastly, 
under  this  neurilemma  were  observed,  in  several  places,  granu- 
lar bodies  resembling  those  met  with  in  certain  foci  of  soften- 
ing. Authors  regard  it  as  possible  that  in  the  filaments  con- 
taining some  healthy  tubes,  and  others  altered,  the  former  may 
have  belonged  to  sensory,  and  the  altered  ones  to  the  motor 
element.  Lorain  and  Lepine  speak  of  the  autopsy  of  a  simi- 
lar case  made  by  one  of  them.  In  another  of  the  same  kind 
which  he  reports,  Biihl  found  small  bloody  extravasations  in 
the  brain  with  peripheral  softening;  and  at  the  point  of  union 
of  the  anterior  and  posterior  roots  of  the  cord  including  the 
spinal  ganglions,  they  had  a  volume  nearly  double  and  were 
colored  dark  red  by  hemorrhagic  infarctus,  which  already 
presented  signs  of  yellow  softening.  This  tumefaction  was 
caused  by  infiltration  of  the  nerve  sheaths  and  of  the  inter- 
stitial connective  tissue,  by  these  neucleolar  bodies  which 
Biihl  regards  as  the  characteristic  lesion  of  diphtheria,  and 
which  he  found  in  the  false  membranes,  in  the  mucous  mem- 
branes covered  by  them,  and  even  in  those  which  appear 
healthy.  These  enlargements  existed  particularly  in  the  lum- 
bar region ;  they  were  less  marked  in  the  cervical,  and  still 
less  in  the  dorsal.  The  cord  was  healthy;  the  nerve  trunks 
were  not  examined.  Oertel  has  found  at  the  autopsy  capil- 
lary hemorrhages  in  the  cranial  and  spinal  dura  mater,  as  well 
as  in  the  nerve  roots  and  peripheral  nerves.  Leyden,  cited  by 
Senator,  has  shown  in  one  case  that  it  is  a  true  case  of  mi- 
grating neuritis  (neuritis  migrans)  starting  from  the  diseased 
organ  and  ascending  toward  the  centers  as  far  as  the  medulla 


PATHOLOGICAL    ANATOMY.  12/ 

oblongata,  by  encroaching  upon  the  nerves  step  by  step. 
Finally,  in  a  subject  who  died  of  asphyxia  in  the  course  of 
diphtheritic  paralysis,  Liouville,  quoted  by  Bailly,  has  found 
the  phrenic  nerves  altered  in  the  same  way  as  the  palatine 
nerves  of  the  patient,  who  was  the  subject  of  the  observation 
made  by  Charcot  and  Vulpian ;  the  degree  of  alteration  was 
only  a  little  less  advanced. 

Section  9.     Locomotor  Apparatus. 

The  muscles  only,  in  the  locomotor  apparatus,  should  en- 
gage our  attention.  In  the  chapters  which  refer  to  the  larynx 
and  heart  I  have  shown  the  changes  which  may  affect  the  mus- 
cular fibres  of  these  organs.  We  have  seen,  moreover,  that 
the  paralyzed  muscles,  those  of  the  palate  especially,  undergo 
fatty  degeneration. 

The  general  muscular  system  is  ordinarily  healthy,  but  docu- 
ments upon  this  subject  are,  however,  rare.  Authors  who  have 
treated  of  muscular  pathology,  viz.,  Zenker,  Waldeyer, 
Hayem  and  Bernheim,  have  not  mentioned  the  modifications 
made  by  diphtheria;  those  who  have  spoken  of  it  have  had  in 
view  only  the  lesions  of  muscles  contiguous  to  the  inflamed 
mucous  membranes.  However,  we  may  establish  the  fact  that 
certain  muscles  are  sometimes  attacked  with  fatty  transforma- 
tion. In  one  of  the  observations  of  L.  Lagrave  the  muscles 
examined  by  Damaschino  presented  the  peculiarities  of 
waxy  degeneration.  In  all  these  cases  paralysis  was  not 
noted. 

Section  10.     Organs  of  the  Senses. 

I.  The  Eye. — The  ocular  mucous  membrane,  like  all  the 
membranes  of  this  order,  is  subject  to  be  covered  with  diph- 
theritic productions.  The  different  names,  pseudo-membran- 
ous ophthalmia  (Bouisson),  conjunctival  diphtheria  (Laboul- 
bene),  croup  of  the  eyelids  (Magne),  diphtheritic  opthalmia 
(Gibert),  and  (Raynaud),  and  palpebral  diphtheria  (Peter),  have 
been  applied  to  this  diphtheritic  manifestation  by  authors  who 
have  described  it.     The  false  membrane  shows  itself  by  pref- 


128  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

erence  upon  one  or  both  of  the  divisions  of  the  palpebral  con- 
junctiva.    More  rarely  it  attacks  the  ocular  conjunctiva.     At 
first  it  is  white,  thin  and  very  adherent,  and  can  be  torn  off 
only  in  fragments,   causing  some  bleeding.     Sometimes  it  is 
more  feebly  attached,  and  may  be  separated  all  in  one  piece. 
At   a   later  period   it  becomes  gray  and  thicker.     The    con- 
junctiva is  thickened  and  strongly  injected  at  first;  then  it  be- 
comes glossy,  smooth,  and  of  a  pale  gray  or  yellowish  color, 
and  the  circulation  then  is  imperfectly  accomplished,  there  is 
a   real   ischaemia.     The   sub-jacent   connective   tissue   is   infil- 
trated and  tumefied;  the  skin  which  covers  it  is  glistening  and 
tense.     The  conjunctiva  may  be  attacked  alone,  but  the  cor- 
nea is  often  encroached  upon,  not  by  the  diphtheria,  but  by  a 
violent   inflammation   in   the  vicinity.     Sometimes   it    is  only 
abraded,  but  it  may  be  ulcerated.     This  is  the  result  of  imper- 
fect nutrition,  the  consequence  of  ischaemia.     In  other  cases 
still  more   grave  I  have  seen   an  abscess  develop  in  its  sub- 
stance ;   I  have  also  witnessed  its  perforation  ;  the  eye  w^as  then 
emptied   of  its   aqueous   humor,   and  the  remaining  layers  of 
the  cornea  were  greatly  softened.     It  did  not  appear  that  the 
deep  parts  of  the  eye  had  suffered  greatly.     There  are  cases, 
however,    the    contrary    of  this,    in  which   one  meets  all  the 
lesions  characteristic  of  suppuration  of  the  globe.     The  mus- 
cles which  preside  over  the  movements  of  the  eye   and  over 
accommodation  of  its  various  parts  are  certainly  affected,  since 
we    observ^e  strabismus,   amblyopia,    mydriasis  and    blepharo- 
tosis;  but    I  believe    they   have  not  been  examined   anatom- 
ically.    At  the  same  time  with  diphtheritic  conjunctivitis  vari- 
ous localizations  of  diphtheria  in  other  regions  are  met  with, 
the  most  common  of  which  is  tliat  of  the  integument. 

2.  The  Ear. — When  diphtheria  attacks  the  ear  grave  lesions 
are  produced  in  this  organ.  It  is  through  the  Eustachian  tube 
that  the  disease  is  propagated  from  the  pharynx  to  the  middle 
ear.  This  duct  alone  is  sometimes  attacked,  and  the  exu- 
date moulds  itself  upon  its  surface  and  takes  the  form  of  a 
trumpet.  But  frequently  the  process  penetrates  into  the  mid- 
dle ear,  there  produces  irreparable  destruction,   detaches  the 


PATHOLOGICAL    ANATOMY.  I  29 

ossicles  and  perforates  the  membrana  tympani,  which  permits 
the  false  membrane  to  extend  to  the  meatus  and  auricle. 
Aside  from  the  presence  of  the  exudate  which  is  deposited 
upon  the  entire  surface  of  the  middle  ear  and  upon  the  exter- 
nal meatus,  the  disturbances  met  with  are  those  of  otitis  media. 
But  I  need  not  describe  them  more  in  detail.  The  external 
parts  of  the  ear,  the  pinna,  and  especially  the  groove  which 
separates  it  from  the  cranium,  are  the  seat  of  ulcerations  cov- 
ered with  diphtheritic  concretions.  These  are  lesions  which 
really  belong  to  cutaneous  diphtheria. 

3.  The  Nose  and  Nasal  Fosses. — These  parts  have  been 
treated  in  the  chapter  relating  to  the  air-passages. 

SYMPTOMS. 

Divisions. — Like  all  general  and  infectious  diseases,  diph- 
theria reveals  itself  by  local  phenomena  and  by  general  symp- 
toms. The  former  are  constant,  with  rare  exceptions ;  the  lat- 
ter, very  variable  as  to  their  intensity,  are  obscure,  moderate, 
or  predominant.  Among  the  local  phenomena  the  most  im- 
portant, beyond  doubt,  is  the  false  membrane.  It  is  the  al- 
most unfailing  characteristic  of  the  disease.  All  observers 
have  verified  its  presence  on  different  organs,  and  they  have 
described  the  morbid  conditions  as  well  as  the  local  deter- 
minations, whence  the  names  membranous  angina,  croup,  etc. 
To  each  of  these  names,  in  fact  to  each  invasion  of  an  organ, 
corresponds  a  totality  of  symptoms — a  cry  of  the  diseased  or- 
gan which  expresses  the  disturbances  produced  in  the  normal 
action  of  the  latter.  These  different  symptomatic  aggrega- 
tions (complexus)  form  groups  quite  accurate  and  very  dis- 
tinct. It  is,  therefore,  expedient  in  the  description  of  diph- 
theria to  make  divisions,  each  having  as  a  caption  the  local- 
ization of  the  false  membrane.  Thus  we  shall  have  to  present 
angina,  croup,  bronchitis,  cutaneous  diphtheria,  etc.  But  aside 
from  the  false  membrane  and  symptoms  which  are  the  direct 
consequences  of  it,  general  phenomena  exist  and  derange- 
ments belonging  to  the  several  general  systems,  derangements 


130  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

which  are  common  to  all  the  localizations  of  diphtheria. 
These  are  the  signs  of  diphtheritic  infection.  Thus  there  are 
two  grand  divisions  of  symptoms.  One  set  are  the  expression 
of  the  general  disease,  and  they  belong  to  the  general  de- 
scription of  diphtheria.  The  other  take  their  characteristics 
from  the  situation  of  the  false  membrane,  and  they  will  find 
their  place  in  the  description  of  the  localisations  of  dipJitheria. 
According  to  another  classification,  based  upon  etiology  and 
adopted  long  ago,  diphtheria  is  considered  as  different  accord- 
ing as  it  is  primary  or  secondary.  This  disease  often  being 
influenced  in  its  course  and  in  its  gravity  by  its  origin,  this  dis- 
tinction appears  well  founded.  However,  the  modifications 
which  result  from  etiological  influences  are  not  peculiar  to  the 
latter,  and  we  find  them  frequently  in  the  primary  form. 
There  is,  therefore,  no  ground  for  admitting  a  secondary 
diphtheria  different  from  the  primary;  it  is  proper  only  to 
make  conspicuous  the  peculiar  physiognomy  assumed  by  the 
disease  in  each  case  in  which  it  is  engrafted  upon  a  previous 
morbid  state,  and  to  show  that  though  the  course  and  general 
symptoms  are  not  to  be  distinguished  from  those  of  primary 
diphtheria,  it  is  no  longer  the  same  when  we  consider  the  lo- 
calizations. These  nearly  always  recall  in  their  arrangement 
the  local  manifestations  of  the  original  disease.  In  a  prog- 
nostic point  of  view  secondary  diphtheria  deserves  also  a  sep- 
arate notice.  For  these  reasons  I  shall  preserve  the  classic 
division  into  primary  diphtheria  and  secondary  diphtheria^  while 
assigning  much  less  importance  to  the  latter. 


\ 


ARTICLE     FIRST.  —  GENERAL    DESCRIPTION     OF 
DIPHTHERIA. 


Primary  Diphtheria. 


Taking  it  in  its  simplest  acceptation,  diphtheria  is  a  general, 
infectious  and  contagious  disease,  of  which  the  local  mani^ 
festations,  presenting  themselves  on  the  part  of  the  mucous 
membranes  and  the  skin,  are  accompanied  at  one  time  feebly, 
at  another  strongly,  with  general  sympoms,  which  latter  reveal 
its  septic  nature.  These  two  elements  are  associated  in  very 
variable  proportions.  At  one  time  the  local  element  appears 
to  dominate  exclusively,  the  septic  element  remaining  in  a 
latent  itate;  but  while  being  predominant  the  former  does  not 
assume  an  extensive  development.  When  it  extends  it  always 
does  so  by  contiguity;  it  does  not  appear  simultaneously  hor 
consecutively  at  distant  points.  In  another,  the  local  symp- 
toms are  distinguished  by  their  tendency  to  spread.  Not  only 
do  they  extend  locally  with  a  remarkable  activity,  but  they 
soon  appear  upon  the  points  more  or  less  distant  from  the 
point  of  departure.  At  this  time  toxic  symptoms  suddenly 
appear,  which  are  frequently  absent  at  first.  In  a  third  class 
the  local  condition  is  nearly  absent,  but  the  intoxication  domi- 
nates the  scene  from  the  beginning.  These  tliree  forms  (mo- 
dalites)  represent  diphtheria  under  its  principal  aspects;  it  pre- 
sents three  types  which,  while  conserving  to  the  disease  its 
unity,  renders  the  description  more  easy  of  apprehension. 
They  constitute,  properly  speaking,  the  symptomatic  forms  of 
the  disease.  I  shall,  therefore,  assign  to  diphtheria  three 
forms,  each  corresponding  to  one  of  the  preceding  models, 
viz.,  a  benign,  an  infections,  and  a  malignajit  form.  Each  lo- 
calization of  diphtheria  may  assume  any  one  of  these  forms. 
From  this  relationship,  taking  angina  as  an  example,  there  will 
follow  angina  of  a  benign,  an  infectious,  or  of  a  malignant 
form. 


132  diphtheria,  croup  and  tracneotomy. 

Forms. 

Benign  Form. — We  find  this  form  most  frequently  in  the 
throat ;  and  it  occurs  again  primarily  in  the  larynx,  in  the 
cases  of  primary  croup  (croup  d'emblee).  It  commences  by  a 
febrile  movement,  sometimes  imperceptible,  more  frequently 
quite  marked,  usually  accompanied  with  a  slight  and  repeated 
chill,  an  onset  like  one  of  the  non-diphtheritic  inflammatory  an- 
ginas, provided  they  acquire  a  certain  violence.  At  the  same 
time  there  is  anorexia,  extreme  lassitude  and  headache.  The 
local  condition  varies  greatly.  Often  the  false  membrane  is 
quite  limited;  sometimes  it  is  simply  dotted,  and  assumes  that 
form  which  Gubler  has  separated  from  diphtheria,  giving  it  the 
name  of  herpetic  angina.  It  maintains  these  dimensions  or  ex- 
tends superficially  while  still  remaining  confined  to  the 
pharynx.  Finally,  it  may  happen  that  it  will  extend  from  the 
pharynx  and  gradually  reach  the  larynx.  If  in  this  case  the 
patient  runs  certain  dangers,  these  belong  to  the  situation  of 
the  exudate,  but  the  disease  remains  none  the  less  benign  as 
to  diphtheria,  and  as  soon  as  one  has  relieved  the  asphyxia  by 
appropriate  means  the  cure  is  effected  without  difficulty.  This 
form  of  diphtheria  is  found  almost  entirely  in  angina ;  and  I 
transfer,  therefore,  to  the  description  of  the  latter  what  remains 
to  be  said,  so  as  to  avoid  repetition.  Adenitis  is  often  ob- 
served with  the  benign  form,  and  it  is  never  very  considerable. 
Trousseau  attaches  great  importance  to  the  glandular  swell- 
ing in  angina  ;  it  was  to  him  a  phenomenon  pathognomonic  of 
diphtheria.  In  accord  with  many  authors,  I  shall  be  less  posi- 
tive, so  much  the  less  so  as  adenitis  is  met  with  in  certain 
cases  of  intense  simple,  yet  inflammatory  angina.  While  not 
common,  albuminuria  is  still  not  very  rare.  Its  duration  is 
short,  not  exceeding  six  or  eight  days.  Paralysis  of  the  soft 
palate  or  other  organs  sometimes  intervenes  during  conva- 
lescence. 

Infections  Form. — The  commencement  is  the  same  as  in  the 
above  form,  but  at  the  end  of  a  few  days  characteristic  symp- 
toms appear.      Most  frequently  the  false  membranes  first  ap- 


GENERAL    DISCRIPTION    OF    DIPHTHERIA.  1 33 

pear  in  the  throat,  but  sometimes  they  show  themselves  there 
after  having  attacked  other  mucous  membranes,  or  the  skin  at 
the  point  of  an  accidental  wound,  or  on  the  surface  of  a  blister 
or  an  old  ulcer.  Instead  of  occupying  limited  points  of  the 
throat  they  extend  as  a  simple  patch,  which  covers  the  soft 
palate,  its  pillars,  and  the  tonsils  (Barthez).  Their  color  be- 
comes gray  or  dark  gray,  and  they  assume  a  gangrenous  ap- 
pearance and  fotid  odor.  The  mucous  membrane  becomes 
tumefied,  violet-colored,  bleeds  easily,  and  even,  in  some  cases, 
mortifies.  When  the  false  membrane  has  attacked  the  throat 
first,  it  is  seen  to  extend  into  the  nasal  fossae,  the  larynx  and 
the  bronchi;  and  it  breaks  out  on  wounds,  at  points  of  the 
skin  denuded  of  epidermis,  on  the  place  of  old  cutaneous  af- 
fections, upon  the  conjunctiva,  the  lips,  and  upon  the  genital 
organs;  everywhere  it  assumes  the  same  characteristics.  The 
mucous  membrane,  even  that  of  the  larynx,  and  the  skin  may 
become  gangrenous.  The  lymphatic  ganglions,  around  the 
regions  attacked,  are  considerably  enlarged,  and  they  often 
suppurate.  The  atmosphere  of  connective  tissue  which  sur- 
rounds them  participates  more  or  less  in  the  ganglionary  in- 
flammation. The  infectious  character  may  still  depend  upon 
the  generalization  of  false  membranes  without  assuming  the 
gangrenous  character  and  without  their  development  being 
accompanied  with  adenitis.  Thus  it  is  that  one  sees  the  dis- 
ease remain  limited  to  the  throat  during  several  days,  with  all 
the  appearance  of  benignity,  and  then  extend  suddenly  to  the 
larynx  and  bronchial  tubes.  There  is  usually  fever;  the  pulse 
is  small  and  feeble.  The  complexion,  at  first  bright,  becomes 
pale,  livid,  leaden,  and  the  mucous  membranes  become  cyan- 
osed  without  there  being  any  predominance  of  asphyxia.  The 
dejected  countenance  bears  the  imprint  of  sadness.  The  vital 
forces  are  considerably  diminished.  Haemorrhages  appear 
from  different  passages,  especially  from  the  nose,  sometimes 
from  the  mouth,  the  anus,  or  the  bladder.  A  decided  anaemia 
is  the  result  of  this  condition,  less,  however,  from  the  loss  of 
blood  than  from  the  disease  itself,  which  increases  the  genesis 
of  white  blood  globules.     We  have   seen   in  the  pathological 


134  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

anatomy  that  the  number  of  these  bodies  might  be  increased 
in  considerable  proportion.  Intestinal  symptoms  are  not  com- 
mon when  not  produced  by  emetics ;  however,  P.  Wilson  and 
Eisenmann  notice  their  frequency  (?).  Greenhow  cites  a  fatal 
case  of  haematemesis  in  a  case  of  diphtheria,  the  patient  being 
a  boy  of  15.  Albuminuria  is  more  frequent  than  in  the  benign 
form.  The  cerebral  phenomena  are  slight  and  intellection  is 
perfectly  clear.  Convulsions,  however,  are  sometimes  ob- 
served, either  at  the  beginning,  as  in  many  of  the  diseases  of 
children,  or  at  the  termination.  This  form  of  diphtheria  is 
grave,  and  often  ends  fatally.  Yet  recovery  is  not  very  rare, 
and  it  is  more  frequent  in  proportion  as  the  false  membranes 
are  more  localized  and  the  general  condition  less  compro- 
mised. When  death  occurs  it  is  due  principally  to  exhaustion 
and  to  the  depraved  condition  (cachexia)  into  which  the  pa- 
tients sink.  Death  by  asphyxia  alone  is  less  frequent;  and 
carbonic  acid  intoxication,  while  arising  under  various  circum- 
stances, when  the  larynx  or  bronchial  tubes  are  covered  with 
false  membranes,  is  never  only  one  of  the  factors  in  a  product 
to  which  septicaemia  largely  contributes,  Patients  who  do 
not  succumb  rapidly  seldom  escape  paralysis  of  various  or- 
gans. The  duration  is  long.  Of  the  three  forms  of  diphtheria, 
the  infectious  is  the  most  prolonged.  It  is  to  this  form  that 
belong  those  cases  in  which  the  false  membranes  are  repro- 
duced with  remarkable  tenacity,  and  which  Barthez  has  pro- 
posed to  include  in  a  fourth  form,  which  he  calls  the  chronic 
form.  Isambert  reports,  in  this  class,  the  history  of  a  house 
surgeon  who,  having  been  attacked  with  nasal  diphtheria,  con- 
tinued for  several  months  to  expel  from  his  nose  false  mem- 
branes. 

The  Malignant  Form. 

This  form  is  characterized  by  the  predominance  of  the  toxic 
element.     It  presents  two  varieties. 

In  the  first,  which  may  also  be  called  the  explosive  form 
(forme  foudroyante),  the  symptomatic  complex  is  the  same  as 
in  the  preceding  form,  and  is  distinguished  from  it  only  by  the 


GENERAL    DISCRIPTION    OF    DIPHTHERIA.  I35 

rapidity  with  which  the  symptoms  follow,  and  death  may  su- 
pervene in  twenty-four  hours,  or  in  forty-eight,  as  in  the  case 
of  Valleix,  or  in  three  or  four  days  at  farthest.  It  is  not  propa- 
gation to  the  larynx  which  causes  the  fatal  termination  ;  the 
false  membranes  have  often  not  time  to  extend  that  far.  It  is 
a  veritable  blasting.  In  other  cases  false  membranes  arise  on 
all  sides  with  frightful  rapidity;  in  a  day  or  two  the  throat, 
the  nose,  the  larynx,  the  bronchial  tubes,  different  points  of 
the  skin,  the  conjunctiva,  the  genital  organs,  etc.,  may  be  in- 
vaded to  such  an  extent  that  healthy  mucous  membrane  is  no 
longer  to  be  found.  Even  in  these  local  conditions  the  gen- 
eral state  predominates.  The  local  symptoms  present  nothing 
new,  except  it  be  an  exaggeration  of  the  gangrenous  symp- 
toms, increase  of  the  offensive  odor,  which  becomes  perfectly 
intolerable,  the  violet  tint  of  the  mucous  membranes,  and  the 
greater  tendency  to  hemorrhages.  We  must  not  suppose  that 
the  false  membranes  are  always  very  extended;  on  the  con- 
trary, one  is  often  surprised  to  find  them  on  one  side  only,  and 
of  little  extent,  or  almost  absent.  But,  however  limited  they 
may  be,  the  neck  always  presents  an  enormous  tumefaction ; 
this  latter  is  the  characteristic  of  this  form.  This  swelling, 
which,  according  to  the  figurative  expression  of  Trousseau, 
"sent  sa  peste;"  pestiferi  inorbi  naturani  redolens,  said  Mer- 
cado,  is  not  formed  alone  at  the  expense  of  the  inflamed 
cervical  and  parotid  glands,  it  includes  the  surrounding 
connective  tissue  also.  The  general  symptoms  and  the 
signs  of  cachexia  are  still  more  marked,  viz.,  prostration,  small 
and  weak  pulse,  chilliness,  and  sometimes,  at  the  close,  de- 
lirium ;  very  often  there  is  somnolence  or  coma,  throughout 
the  entire  duration  of  the  disease.  This  variety  is  always 
fatal. 

The  second  variety  merits  the  name,  insidious  form.  It 
leads,  in  the  beginning,  to  the  expectation  of  benignity,  which, 
however,  becomes  painfully  deceiving.  The  lesions  are  unim- 
portant, but  they  extend  to  the  throat  and  nose ;  their  appear- 
rnce  has  not  always  the  special  characteristics  above  de- 
scribed; but   the    general    condition   is   profoundly    affected. 


136  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

The  fever,  it  is  true,  is   often  absent,  the  pulse   not  very  fre- 
quent,  but  weak   and    miserable,   the    countenance    pale    and 
leaden,  the  eyes  with   dark   circles  around   them,  the  disgust 
for  food  insurmountable,   depression  of  the  vital  forces  com- 
plete, and  the   swelling   of  the   cervical  glands  is   enormous. 
However,  at  the  .end  of  from  five  to  eight  days  the  local  con- 
dition improves,  even  recovers,  but  the  prostration  continues, 
increases,  the  pulse  becomes  slower,  and  the  patient  cold,  the 
prey  of  a  constant  agitation,  or  remains  in  an   absolute  quiet- 
ude, which  contrasts  with  the  gravity  of  the  situation ;  then  he 
dies  by  progressive   marasmus,  or  suddenly.     In  other  cases 
the  insidious  character  is  still  more  striking.     The  local  lesions 
are  ill-expressed,  the  fever   is    absent,  and   the  patient  suffers 
but  little  ;  he  remains  up,  walks  about,  and  appears  not  at  all 
concerned  about  his  condition.     But  the  countenance  is  char- 
acteristic, and  the  cervical  swelling  is  considerable.     Then,  at 
the  end  of  a  few  days,  the  patient  dies  suddenly,  while   mov- 
ing, during  an   effort,   or,    indeed,    sinks   rapidly   from  general 
conditions  which    suddenly   develop.     The  termination   is  al- 
ways fatal.     Albuminuria  is   frequently  met  with  in  both  ot 
these  varieties. 

ANALYSIS    OF   SYMPTOMS. 

Among  the  symptoms  which  have  just  been  enumerated, 
some  are  peculiar  to  certain  localizations;  they  will  be  studied 
with  them.  Others  are  independent  of  forms  and  localiza- 
tions. Without  being  constant,  they  are  found  in  forms  most 
benign,  as  well  as  in  those  most  severe,  in  localizations  the 
most  various,  and  in  the  most  extended  as  well  as  the  most 
circumscribed.  Their  place  is  noted  in  the  general  history  of 
diphtheria.  They  are  fever,  albuminuria  and  eruptions.  Others 
vary  according  to  the  different  forms ;  they  are  the  inheritance 
(apanage)  of  the  infectious  forms  on  which  they  place  their 
stamp  of  gravity.  In  this  sense  they  may  be  described  as 
complications.  But  admitting  that  they  are  the  same  grave 
accidents  which  characterize  the  forms  of  diphtheria,  I  do  not 
hesitate  to  think  that  their  description  may  enter  into  that  of 


t 


GENERAL    DISCRIPTION    OF    DIPHTHERIA.  1 3/ 

the  symptoms  of  diphtheritic  disease.  I  shall  therefore  study 
them  after  those  of  the  primary  group.  One  will  there  find 
gastro-intestinal  disturbances,  gangrene,  hemorrhages,  oedema 
without  albuminuria,  and  derangements  of  the  circulatory  ap- 
paratus. Afterwards  will  come  the  nervous  disturbances,  con- 
vulsions and  diphtheritic  paralysis.  After  having  devoted  a 
few  words  to  the  variations  which  the  urine  undergoes  in  its 
quantity  and  in  its  composition  I  shall  close  by  some  consid- 
erations upon  secondary  diphtheria. 

FEVER. 

Fever  is  one  of  the  most  variable  phenomena  of  diphtheria. 
In  certain  epidemics  and  in  some  sporadic  cases  it  fails  com- 
pletely, or  almost  so.  In  the  most  simple  cases  the  fever  is 
often  intense  at  the  onset.  In  malignant  cases  it  may  be  at 
zero.  If  it  be  present  it  may  rapidly  diminish  while  the  pulse 
is  becoming  small  and  the  extremities  cold.  On  the  other 
hand,  a  persistent  fever  is  not  regarded  either  as  a  favorable 
omen.  It  is  therefore  not  so  much  the  presence  or  absence 
of  fever  which  we  must  consider,  but  rather  the  period  of  its 
appearance,  its  persistence,  and  the  symptoms  which  accom- 
pany it.  An  intense  fever  at  the  beginning  is  not  of  serious 
import  when  it  disappears  without  the  forces  being  depressed. 
If,  on  the  contrary,  it  persist,  or  if  after  having  disappeared  it 
return;  if  it  appear  at  a  period  somewhat  remote  from  the  in- 
vasion, it  has  more  importance  because  it  indicates  the  ap- 
pearance of  an  untoward  complication.  It  should  be  examined 
in  its  three  elements :  Temperature,  pulse,  and  respiration. 
The  teniperatiire  has  been  especially  studied  in  croup.  Not- 
withstanding the  modifications  impressed  upon  the  course  of 
the  temperature,  certain  functional  derangements,  such  as  as- 
phyxia and  inflammatory  complications,  there  is  a  quite 
marked  resemblance  between  the  temperature  curve  of  croup 
and  that  of  diphtheria  when  the  latter  is  exempt  from  those 
two  perturbing  causes.  It  is  in  the  relatively  slight  elevation 
that  this  analogy  is  expressed  most  strongly.  To  the  con- 
trary of  what  occurs  in  many  diseases,  the  rise  of  temperature  is 


138  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

not  in  direct  proportion  to  the  intensity  of  the  process.  This 
is  the  only  important  peculiarity  revealed  in  the  study  of  tem- 
perature in  diphtheria.  All  authors  have  observed  it.  Wun- 
derlich  demonstrated  that  there  was  no  other  acute  disease  in 
which  the  temperature  is  so  little  characteristic  as  in  pharyn- 
geal diphtheria  and  in  croup  of  the  larynx.  While  admitting 
that  a  very  high  temperature  constitutes  an  increase  of  danger, 
he  adds  that  a  moderate  temperature,  even  normal,  does  not 
furnish  the  least  guarantee  of  a  favorable  issue,  and  that  the 
elevated  temperature  may  descend  while  the  disease  pro- 
gresses with  an  excessive  fever  until  the  individual  succumbs. 
Roger  observes  that  animal  heat  is  increased  in  croup,  but 
much  less  than  one  might  suppose  from  the  rapidity  of  the 
pulse  and  from  the  acceleration  of  the  respiratory  movements. 
Lorain  and  Lepine  teach  that  diphtheritic  poison  is  not  re- 
markably pyrogenous.  The  diphtheritic  infection  does  not  re- 
veal itsell  by  a  febrile  movement  of  any  importance.  The 
fever  of  an  infectious  angina  may  not  exceed  that  of  an  an- 
gina without  infection ;  one  may  see,  especially  in  children, 
the  temperature  the  first  few  days  sink  below  normal,  and 
death  occur  in  collapse.  The  results  of  my  researches  accord 
with  these  data.  In  the  greatest  number  of  cases,  in  the  mild- 
est as  well  as  in  the  most  severe,  the  temperature  from  the  be- 
ginning varies  between  38°. 2  (101°  F.)  and  38°. 8  (102°  F.); 
several  times,  among  others  in  a  case  of  generalized  diphthe- 
ria, I  have  seen  it  mark  36°. 8  (98°. 2  F.).  Under  other  cir- 
cumstances, finally,  the  invasion  was  marked  by  temperatures 
oscillating  between  39°  and  40^.4  (  I02°.4  F.  and  105°  F.). 
But  then,  complications,  such  as  bronchitis,  broncho-pneumo- 
nia, pneumonia  or  convulsions,  had  supervened,  or  were  immi- 
nent. In  speaking  of  the  beginning  I  did  not  mean  the  real 
beginning  or  date  at  which  the  patient  began  to  be  indisposed. 
This  moment  nearly  always  escapes  the  observer ;  it  is  rarely 
that  the  physician  is  called  before  the  formation  of  false  mem- 
branes. At  least,  with  very  exceptional  cases,  one  is,  there- 
fore, obliged  to  be  content  with  this  date.  However,  Squire, 
and  Callandreau  Dufresse,  who  cites  him,  appear  to  have  been 


GENELAL    DISCRIPTION    OF    DIPHTHERIA.  1 39 

more  fortunate,  since  they  admit  a  period  of  incubation  which 
reveals  itself  by  an  elevation  of  temperature,  an  elevation 
which  they  do  not  give  precisely,  and  which  may  diminish 
when  the  local  manifestations  appear.  I  cannot  admit,  with- 
out farther  information,  this  assertion,  inasmuch  as  in  two  cases 
in  which  the  patients  could  be  observed  during  the  initial  pe- 
riod, these  conditions  occurred  reversed.  In  the  first  patient 
the  temperature  was  38°. 5  (101°. 3  F.)  when  the  throat  pre- 
sented only  redness,  but  rose  to  38'^./  (101°./  F.),  when  the 
exudation  appeared.  In  the  second  the  difference  is  much 
more  striking.  Taken  under  the  same  circumstances  the  tem- 
perature rose  from  38^.4  to  40^.4  (F.  ioi°.i-i04''.7).  When 
the  disease  is  established  the  temperature  curve  rises  accord- 
ing as  the  process  advances  towards  recovery  or  towards 
death.  In  the  former  case  the  curve,  if  there  be  no  complica- 
tions, falls  to  normal  at  the  end  of  two  or  three  days,  either 
suddenly  or  after  a  few  oscillations.  If  diphtheria  reach  the 
larynx,  modifications  arise  which  I  shall  present  in  detail  when 
speaking  of  croup.  If  certain  complications  appear  the  curve 
rises,  reaches  a  higher  point  than  at  the  beginning,  remains 
between  39°  and  40°  (l02°  and  104°  F.)  during  the  time  the 
complication  continues  active,  then  resumes  its  descent  at  a 
period  varying  with  the  nature  and  intensity  of  the  complica- 
tion ;  sometimes  a  local  determination  upon  another  point,  a 
new  impulse,  or  simply  the  appearance  of  paralysis  causes  it 
to  ascend.  In  the  /atUr  case  the  temperature  rises  rapidly  to 
39°  or  40°  (I02°-I04°  F.),  and  even  above ;  or,  after  a  rapid  ora 
progressive  decline,  to  a  little  below  normal,  the  patient  dies 
in  a  kind  of  collapse.  The  temperature  in  this  latter  case  no 
longer  expresses  the  gravity  of  the  situation,  as  it  does  in  so 
many  other  diseases.  Dr.  Faralli  has  reached  similar  con- 
clusions. He  admits,  moreover,  that  in  the  infectious  and 
malignant  forms,  the  mercurial  column  continues  to  rise  till 
the  death  of  the  patient.  We  have  seen  by  what  precedes 
that  the  latter  proposition  is  not  always  verified.  The  details 
just  given  confirm  what  I  advanced  at  the  beginning  of  this 
chapter,  viz.,  that  the  course  of  the  temperature  furnishes  but 


140  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

imperfect  and  even  negative  indications  of  the  course  of 
the  disease.  The  only  interesting,  and  perhaps  useful  fact  re- 
sulting from  this  study  is  the  slight  elevation  of  temperature 
developed  by  diphtheria  when  abandoned  to  itself.  The  pulse 
is,  ordinarily,  frequent  in  uncomplicated  diphtheria;  it  rises  to 
120,  to  140,  or  even  higher,  according  to  age.  Relatively 
more  elevated  than  the  temperature,  it  follows,  however,  the 
latter  in  its  ascent,  then  descends,  but  not  always  in  the  same 
ratio.  It  often  continues  frequent  for  a  certain  time  after  the 
temperature  has  returned  to  normal.  When  a  complication 
supervenes  it  follows  the  features  belonging  thereto.  In  the 
malignant  and  in  the  infectious  forms,  when  the  latter  termi- 
nates in  death,  the  pulse  sometimes  becomes  small,  weak,  sud- 
denly slow,  and  falls  below  50  pulsations  in  the  minute  ;  a 
decided  reduction,  especially  so  when  it  is  the  case  of  a  young 
child.  In  the  insidious,  malignant  form  it  often  occurs  that 
the  pulse  is  not  modified  even  at  the  beginning.  It  continues 
normal ;  but  when  the  signs  of  malignancy  appear,  when  col- 
lapse supervenes,  it  sinks  as  in  the  former  case. 

The  respiratio7i  generally  follows  pretty  closely  the  tempera- 
ture and  the  pulse  in  their  rise,  from  the  beginning.  It  reaches 
from  36  to  38  respirations  in  the  minute.  If  the  fever  cease 
or  decline  the  respirations  diminish  at  the  same  time.  In  case 
of  fatal  termination,  even  when  the  pulse  may  become  slower, 
the  respiration  becomes  accelerated  and  rises  to  50  or  60,  or 
even  more,  in  the  minute.  The  same  occurs  when  a  thoracic 
complication  supervenes,  and  the  frequency  of  respiration  is 
often  the  best  and  even  the  only  index  of  it. 

ALBUMINURIA. 

Diphtheritic  albuminuria,  signalized  by  Wade,  of  Birming- 
ham, has  been  the  subject  of  study  by  many  authors  who  have 
endeavored  to  throw  light  upon  the  cause  and  the  symptom- 
atology. In  persons  attacked  with  diphtheria  the  color  of  the 
urine  is  variable;  most  frequently  it  is  limpid,  and  of  an  am- 
ber yellow  color.  Sometimes  it  becomes  cloudy  on  cooling, 
which  is  occasioned  by  the  precipitation  of  the  urates  which  it 


GENERAL    DISCRIPTION    OF    DIPHTHERIA.  I4I 

contains  in  sufificiently  large  quantity   alone   or  together  with 
albuminuria.     After  standing  some  days,  and  independently  of 
all  lithate  sediments,  the  microscope  enables    one   to   discover 
often  in  the  inferior  strata  of  the  urine  altered  histological  ele- 
ments coming  from  the  renal   debris,  such   as   blood  globules, 
leucocytes,    epithelial    cells    scattered    or    agglomerated    into 
hyalin  or  fibrinous  cylinders.     The  presence  of  albuminuria  is 
revealed  by   applying,  in  the   usual    manner,  heat   and    nitric 
acid.     The  quantity  is  quite  variable.     At   one   time   the  pre- 
cipitate  is   flocculent   and   quite   abundant,   at  another  but  a 
slight  cloudy  aopearance    is   obtained.     The   sources   of  error 
are  too  well  known  to  occupy  my  time  in  this  work.     There 
is  one,  however,  which  enters  fully  into  the   subject   and  which 
I  cannot  leave  in  obscurity,  so  niuch  the  less,  as  the  rather  ex- 
tensive use  at  this  time  of  the  balsams  may  make  it  more  com- 
mon.    In  fact  the  resin  of  copaiba  is   climated  by  the  urine  in 
which  it  remains  in  suspension,  but  it  is   precipitated   by  nitric 
acid.     The   cloud   produced   by   the   addition   of  this   reagent 
presents   a   strong   analogy   to   that  of  albumen ;   it  is    distin- 
guished from   the  latter  by   being   soluble   in   alcohol.     Thus 
when  the  urine  of  a  patient,  treated  with  the  balsams,  becomes 
cloudy  by  the  action  of  nitric  acid  it  is  necessary  to  add  to  the 
fluid  a  little  alcohol,  which  will  remove  the  precipitate  if  it  has 
arisen  from  resinous  matter.     The   microscope  also   furnishes 
useful   information.     The  albuminous   precipitate  is    granular 
lamellar,  but  never  crystalline.     According   to   the   statements 
of  all  authors,  albuminuria  is  frequent  in  diphtheria.     Accord- 
ing to  Empis  and  Bouchut  one  should  find   it  in   two-thirds  of 
the  cases ;  according  to  See,  in  half,  and  according  to  Mau"-in 
in  the  majority.     My  statements  appear  to  confirm  these  data- 
in  410  cases  of  diphtheria,  in  which  it  was  sought,  it  was  found 
224  times,  that  is,  in   a  little   more  than  half  the   cases.      One 
comprehends   that   it   may  be  difficult   to   fix  exactly  the  fre- 
quency of  this  symptom  ;  albuminuria  being  frequently  a  purely 
transitory,    evanescr-nt.   phenomenon,    statistics,    compiled  with 
the  object  of  establishing  its  frequency,  can   be   of  value  only 
on  condition  that  the  urine  has  been  examined  every  day  from 


142 


DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 


the  invasion  to  complete  recovery.  It  is,  therefore,  possible 
that  certain  ones,  among  those  which  are  known,  are  quite  be- 
low the  facts.  The  appearance  of  albuminuria  does  not  occur 
at  any  fixed  period ;  it  is  from  the  second  to  the  eleventh  day 
that  I  have  found  it  most  frequently.  The  following  table  will 
give  evidence  of  this  statement.  In  224  cases  of  diphtheritic 
albuminuria  the  first  appearance  was  observed  at  the  following 
dates : 

Date  of  Death. 


1st  ( 

Jay 

of  the  di 

2nd 

((                <( 

3rd 

(                (( 

4th 

t(                « 

5th 

(                « 

6th 

<                « 

7th 

t                *( 

8th 

t                t( 

9th 

t                *( 

loth 

1                ti 

nth 

t                t( 

1 2th 

t                (( 

13th 

(                " 

14th 

<                « 

15th 

(                «( 

sease 


i6th,  19th,  23d,  26th,  29th,  37th,  38th,  each, 


No.  of  Cases. 

3 

lu 

30 
30 

22 
26 

13 

33 
12 

14 
10 

I 

2 

I 

4 
I 


Total,  -  -  -  -  -         224 

Thus,  generally  speaking,  its  greatest  frequency  is  found 
within  the  limits  which  I  have  drawn,  and  we  may,  to  be  still 
more  precise,  show  that  albuminuria  has  appeared  most  com- 
monly between  the  third  and  the  eighth  days ;  the  latter  has 
been  the  period  of  preference.  That  this  table  is  marred  with 
some  inaccuracies  I  readily  concede.  In  hospital^  especially, 
patients  being  rarely  subjected  to  observation  from  the  begin- 
ning of  the  disease,  the  evidence  of  albuminuria  on  the  day  of 
entry  does  not  prove  that  it  did  not  exist  before.  Error  is 
therefore  possible,  even   probable,  and   it  is  proper  to  take  it 


GENERAL    DISCRIPTION    OF    DIPHTHERIA.  I43 

into  account.  But  far  from  weakening  the  results  deduced 
from  this  table,  it  confirms  them,  since  it  aids  in  bringing  the 
appearance  of  the  albuminuria  near  to  the  invasion  of  the  dis- 
ease. Nothing  is  more  irregular  than  the  course  of  diphthe- 
ritic albuminuria.  At  one  time  the  precipitate  is  sudden,  abun- 
dant and  flocculent;  at  another  it  commences  with  an  opaque 
cloud,  which  continues  with  this  characteristic  till  the  time  at 
which  it  disappears,  or  very  rapidly  becomes  thick.  In  certain 
cases,  continuing  only  a  day,  it  may  in  others  remain  sta- 
tionary for  a  considerable  time.  While,  in  general,  continu- 
ous, it  is  sometimes  intermittent,  disappearing,  then  reappear- 
ing at  various  intervals. 

In  eighty  cases  of  diphtheria  terminating  in  recovery  in 
which  albuminuria  had  completely  developed,  I  have  obtained 
the  following  results: 

Duration  of  Albuminuria.  No.  of  Cases. 


-  -  -  -  -         10 

2 
6 

3 

4 

6 

3 

8 

-  -  -  -  -         2 

3 

4 

-  -  -  -  -        2 

-  -  -  -  -        2 

-  -  -  -  -         I 

-  -  -  -  -        2 

Total,  -  -  -  -  -  -       80 

It  appears  that  the  most  common   duration   is  from  one  to 
three  days,  and  in  the  next  rank  is  that  from  one  to  ten  days. 


I 

day 

2 

days 

3 

(( 

4 

(( 

5 

(( 

6 

« 

7 

« 

8 

u 

9 

It 

10 

« 

II 

(( 

12 

(( 

13 

(( 

14 

<( 

15 

« 

16 

' 

17 

« 

19 

u 

22 

« 

26 

<( 

57 

« 

144  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

We  see  also  that  though  albuminuria  may  continue  for  a  longer 
time,  fifteen,  twenty,  and  even  fifty-seven  days,  yet  it  is  only  in 
quite  rare  cases.  I  have  not  seen  a  single  case  in  which  it  has 
become  chronic.  Yet  Gregory  and  Rayer  have  cited  several 
such.  I  think,  in  order  to  reckon  them  with  diphtheria,  one 
must  be  certain  that  scarlatina  had  no  share  in  them.  These 
cases,  however,  admitting  them  to  be  correct,  would  be  ex- 
ceptional. The  albuminuria  of  diphtheria  is  very  rarely  accom- 
panied by  oedema,  the  reverse  of  that  of  scarlatina.  The  rea- 
son of  this  curious  peculiarity  is  found  in  the  fact  which  I  men- 
tioned when  treating  of  the  pathological  anatomy,  namely,  that 
in  scarlatina  the  renal  lesions  occupy,  most  frequently,  both 
kidneys,  while  in  diphtheria  there  is  ordinarily  but  one  of  them 
attacked.  Wade  has  never  noted  dropsy ;  G.  See  has  met  with 
it,  but  much  more  rarely  than  in  scarlatina.  According  to 
Trousseau,  one  does  not  observe  it  once  in  twenty  cases.  For 
my  part,  I  have  assigned  to  it  a  still  lower  proportion,  for  in 
224  cases  of  diphtheritic  albuminuria  I  have  collected  but  seven 
cases  of  dropsy.  I  need  hardly  say  that  I  have  deducted  the 
cases  in  which  albuminuria  and  cellular  infiltration  existed  be- 
fore diphtheria.  Dropsy  did  not  appear  before  the  fifth  day.  At 
one  time  it  appeared  in  the  form  of  anasarca,  at  another  in  that 
of  oedema  of  the  face.  In  one  of  the  patients  it  was  limited  to  the 
larynx.  This  was  in  a  child  attacked  with  infectious  diphthe- 
ritic angina  with  coryza,  adenitis,  and  albuminuria,  in  which 
laryngeal  symptoms  suddenly  appeared  on  the  fifth  day,  fol- 
lowed by  suffocation;  and  it  was  supposed  to  be  a  case  of 
croup.  Tracheotomy,  decided  to  be  necessary,  was  performed, 
but  the  patient  died.  Instead  of  laryngeal  false  membranes, 
which  one  expected  to  find,  the  autopsy  demonstrated  the  ex- 
istence of  lesions  most  characteristic  of  cedema  of  the  glottis. 
In  another  case,  albuminuria  and  dropsy  were  accompanied 
with  extremely  serious  cerebral  symptoms,  disturbances  of  vis- 
ion and  repeated  eclamptic  attacks,  which  carried  off  the  pa- 
tient. The  post  mortem  examination  revealed  a  considerable 
oedema  of  the  meninges  and  ventricles.  I  shall  add  that  in 
nearly  all  these  cases  dropsy  and   albuminuria  arose  simultane- 


GENERAL    DISCRIPTION    OF    DIPHTHERIA.  145 

ously ;  in  one  case,  on  the  contrary,  dropsy  preceded  albumi- 
nuria for  eighteen  days.  Upon  the  causes  of  albuminuria 
there  is  far  from  being  an  agreement.  Empis  and  Bouchut, 
Germe,  andHervieux  give  it  as  resulting  from  croupal  asphyxia. 
According  to  Lorain,  Charcot,  and  Lecorche,  the  cause  is  in  re- 
nal congestion  or  in  slight  parenchymatous  nephritis  analogous 
to  those  visceral  congestions  which  occur  in  fevers,  in  typhus, 
in  typhoid,  etc.  According  to  Gubler  it  is  the  consequence  of 
excess  of  protein  materials  contained  in  the  blood.  The  first 
hypothesis  should  be  discarded,  for  the  reason  that  albuminu- 
ria occurs  in  cases  of  diphtheria  in  which  respiration  experi- 
ences not  the  least  restraint,  in  the  most  simple  angina,  even 
in  diphtheria  confined  to  the  skin.  While  in  croup  asphyxia 
may  be  an  auxiliary  cause  in  consequence  of  visceral  con- 
gestion which  it  engenders,  and  from  carbonization  (anoxe- 
mia), which  leaves  imperfect  the  combustion  of  protein  matter 
and  nothing  farther,  yet  it  should  not  be  removed  from  this 
secondary  rank.  The  hypothesis  of  renal  lesion  combines 
many  correct  reasons.  As  in  fevers  and  in  infectious  diseases, 
visceral  congestions  are  common  in  diphtheria.  Besides,  in 
cases  in  which  albuminuria  was  observed  during  life,  autopsy 
revealed  most  frequently,  on  the  part  of  the  kidney,  anatomical 
alterations  which  vary  from  simple  hyperaemia  to  parenchyma- 
tous nephritis  most  perfectly  marked.  It  is  generally  admitted, 
according  to  clinical  and  experimental  data,  that  in  albuminu- 
ria the  kidneys  are  not  limited  to  a  passive  relation ;  their  role, 
on  the  contrary,  is  active ;  in  other  words,  they  do  not  permit 
the  transudation  of  albumin  only  on  condition  of  their  being 
transformed  or  undergoing  certain  modifications  in  their  struct- 
ure, often  evanescent,  sometimes  more  important,  which  are 
the  instrumental  conditions,  sine  qua  non,  of  filtration.  These 
modifications  are,  as  Lecorche  has  demonstrated,  congestion 
of  the  organ  and  degeneration  of  the  epithelium  of  the  canalic- 
uh.  Excess  of  albumin  in  the  blood  does  not  suffice  to  de- 
termine albuminuria ;  the  proteinous  matter  remains  inclosed 
in  the  vessels  of  the  circulation,  if  the  kidneys  are  not  placed 
in  the  required  structural  conditions.     One  may  object  that  in 


146  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

certain  cases  the  kidneys  appear  healthy,  but  it  is  only  from  ex- 
ternal appearance  that  this  opinion  has  been  given ;  histolog- 
ical examination  has  not  been  made.  Moreover,  the  lesions 
necessary  to  albuminuria,  besides  being  often  slight,  are  in 
many  cases  essentially  evanescent ;  the  congestion  disappears 
rapidly,  the  epithelium  is  quickly  regenerated,  and  the  lesion 
may  have  disappeared  if  the  patient  has  not  died  in  the  height 
of  albuminuria.  The  theory  which  attributes  albuminuria  to 
congestions,  frequently  transitory,  which  arise  in  the  kidneys 
as  well  as  in  other  viscera,  in  diphtheria  as  in  all  general  or  in- 
fectious diseases,  is,  therefore,  supported  by  ver}^  solid  argu- 
ments. While  recognizing  the  necessity  of  an  organic  change 
in  the  kidneys,  Gubler  thought  that  albuminuria  should  recog- 
nize as  the  proximate  cause  the  hyper-albuminous  condition  ot 
the  blood,  and  particularly  in  diphtheria,  the  membranous  diath- 
esis characterized  by  the  excess  of  albumino-fibrinous  exuda- 
tion. Now,  in  the  absence  of  exact  analyses  of  the  blood  in 
diphtheria,  there  is  nothing  to  prove  that  this  disease  is  accom- 
panied with  an  exaggerated  richness  of  proteinous  material  in 
the  blood ;  and  I  have  already  insisted  upon  the  apparent  cer- 
tainty of  the  contrary.  Besides,  experiment  has  proved  that 
excess  of  albumin  in  the  blood  is  not  sufficient  to  determine 
albuminuria.  The  symptomatology  and  the  prognostic  val- 
ue of  albuminuria  have  given  rise  to  numerous  contra- 
dictions. Maugin,  Bergeron  and  Lewin  give  it  great  import- 
ance, in  a  diagnostic  point  of  view.  I  have  shown  how  often 
it  fails,  even  in  the  most  marked  cases  of  diphtheria.  If  from 
its  presence  one  may  infer  the  diphtheritic  nature  of  the  dis- 
ease, he  may  not  apply  the  converse  and  exclud,€  from  diph-^ 
theria  the  cases  in  which  the  urine  does  not  furnish  a  coagu- 
lum  under  the  action  of  special  re-agents.  One  would  expose 
himself  by  this  course  to  sad  mistakes,  and  would  see  patients 
die  with  symptoms  peculiar  to  diphtheria  whom  he  iiad  de- 
clared attacked  with  a  simple  herpetic  angina.  Barbosa  is  of 
the  opinion  that  it  aggravates  the  prognosis  when  it  is  not  the 
result  of  renal  congestion.  See,  on  the  contrary,  has  shown 
that  in  eleven  cases  of  diphtheria  with  albuminuria  he  had  ob- 


GENERAL    DISCRIPTION    OF    DIPHTHERIA.  I47 

tained  six  recoveries,  while  in  sixteen  cases  of  diphtheria  with- 
out albuminuria  nine  had  terminated  in  death.  I  intended  to 
verify,  upon  a  large  scale,  the  conclusions  of  See,  which  I 
readily  accepted,  having  observed  many  times  albuminuria 
quite  intense  in  cases  of  benign  diphtheria,  and  conversely,  the 
absence  of  albuminuria  in  many  cases  of  infectious  or  malig- 
nant diphtheria.  I  have  arrived  at  results  different  in  form, 
but  analogous  in  substance.  In  233  cases  of  diphtheri  ac- 
companied by  albuminuria,  142  died  and  ninety-one  recov- 
ered. In  160  cases  of  diphtheria  in  which  albuminuria  was 
absent,  ninety-seven  patients  recovered  and  sixty-three  died. 
These  figures  show  that  in  the  cases  of  albuminuria  the  mor- 
tality has  greatly  surpassed  the  number  of  recoveries,  and  that 
in  those  in  which  albuminuria  was  wanting  the  reverse  result 
was  produced,  though  with  a  difference  much  less  marked.  It 
appeared,  therefore,  that  albuminuria  exercised  in  fact  an  un- 
favorable influence  upon  the  course  of  diphtheria,  or  rather, 
that  it  was  more  common  in  the  grave  cases.  However,  I 
think  it  necessary  to  be  guarded  in  accepting  the  results  of 
statistical  reports  unconditionally  as  the  expression  of  the 
truth.  Many  other  causes  of  death  are  met  with  in  diphtheria  : 
croup,  operations,  pulmonary  and  other  complications,  which 
tend  much  more  strongly  to  a  fatal  termination  than  albumi- 
nuria. In  examining  the  total  cases  in  which  albuminuria  was 
absent,  one  sees  that  other  causes  were  sufficiently  powerful  to 
cause  death  in  sixty-three  cases  of  160,  that  is,  in  a  lit- 
tle less  than  one-half.  In  those  in  which  albuminuria  existed 
and  which  terminated  fatally,  there  were  at  the  same  time  other 
serious  phenomena.  No  symptom  peculiar  to  albuminuria  ap- 
pear to  have  conduced  to  the  fatal  issue.  In  the  cases  which 
recovered  its  presence  was  revealed  only  by  the  examination 
of  the  urine,  and  its  reaction  on  the  economy  was  nil  in  spite 
of  its  intensity,  occasionally  quite  marked.  If  to  these  con- 
siderations one  add  that  in  the  fatal  cases  albuminuria  is  often 
found  in  very  small  quantity  and  but  transitorily ;  and  if  one 
still  add  that  albuminuria  never,  so  to  speak,  passes  into  the 
chronic  state,  except  in  the  very  rare  cases   in   which   it  is  ac- 


148  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

companied  by  oedema,  recovery  generally  takes  place,  and 
that  in  the  fatal  cases  in  which  autopsy  could  be  made  one 
never  found  those  profound  and  generalized  lesions  which 
characterize  diseases  of  the  kidneys  which  induce  death,  we 
should,  therefore,  conclude  that  diphtheritic  albuminuria  is  an 
epiphenomenon  which  in  the  vast  majority  of  cases  remains 
without  influence  upon  the  course  of  the  disease. 

Eruptions. 

In  1858  G.  See  called  the  attention  of  the  Societe  Medical 
des  hopitaux  de  Paris  to  cutaneous  eruptions  which  he  had 
observed  in  his  service  in  a  certain  number  of  subjects  at- 
tacked with  croup  and  diphtheritic  angina.  They  were  almost 
analogous  to  scarlatina;  some  of  them  resembled  roseola.  See 
did  not  consider  them  as  eruptive  fevers  running  concurrently 
with  diphtheria,  but  as  emanations  of  the  diphtheritic  poison- 
ing, as  cutaneous  manifestations  which  would  be  the  counter- 
part of  those  met  with  in  other  toxic  diseases.  Their  fre- 
quency was  relatively  great ;  they  were  present  at  least  one 
time  in  four.  Numerous  objections  to  this  interpretation  arose  ; 
certain  members  of  the  society  declared  that  the  so-called 
diphtheritic  eruptions  were  unrecognized  scarlatina.  Others, 
while  admitting  the  possibility  of  the  rash  in  diphtheria,  pre- 
sented very  legitimate  reservations  upon  the  frequency  of 
these  phenomena.  Indeed,  while  accepting  as  demonstrated 
the  existence  of  diphtheritic  eruptions  analogous  to  those  ob- 
served in  typhus,  typhoid,  cholera,  rheumatism,  etc.,  it  is  nec- 
essary, in  order  to  be  correct  in  declaring  the  diphtheritic  na- 
ture of  an  exanthema,  to  proceed  by  exclusion,  and  to  exclude 
all  other  causes.  Now,  the  age  of  the  patients,  when  they  are 
children,  and  their  sojourn  at  the  hospital,  are  conditions  which 
strongly  contend  in  favor'of  eruptive  fevers.  The  younger  the 
patient  the  greater  are  the  chances  of  an  eruptive  fever.  And 
first,  it  is  indispensable  to  exclude  all  eruptions  which  appear 
before  the  false  membranes ;  it  is  more  legitimate  to  consider 
them  as  the  primary  disease  of  which  diphtheria  would  be  only 
a   secondary   symptom ;  as  to   those   which   arise    during  the 


GENERAL    DISCRIPTION    OF    DIPHTHERIA.  I49 

course  of  diphtheria,  they,  should,  in  order  to  be  considered  as 
manifestations  of  this  disease,  appear  at  a  period  as  near  as 
possible  to  the  onset,  or  at  least  to  the  entrance  into  the  hos- 
pital ;  it  is  ordinarily  in  the  ward  of  the  hospital  that  patients 
contract  eruptive  fevers  which  complicate  the  disease  for 
which  they  have  been  admitted.  The  incubation  of  scarlatina, 
for  example,  continues,  according  to  Rilliet  and  Barthez, 
Guersant  and  Blache,  from  three  to  five  days  at  the  minimum, 
and  from  five  to  thirteen  days  on  the  average.  The  minimum  of 
incubation  in  measles  varying  from  six  to  ten  days  on  the  av- 
erage, one  should  have  the  right  to  exclude  from  the  list  of 
eruptive  fevers  the  cutaneous  manifestations  which  shall  occur 
in  the  minimum  of  the  space  of  time  fixed  for  the  incubation 
of  these  fevers,  at  least  to  admit  that  diphtheria  and  the  erup- 
tive fever  may  have  been  contracted  at  the  same  time,  as  may 
be,  strictly  speaking,  possible  in  the  time  of  an  epidemic.  The 
eruptions  which  appear  at  a  later  date  should  not,  any  more 
than  the  others,  present  any  of  the  symptoms  which  accom- 
pany measles  and  scarlatina:  ocular,  nasal,  pulmonary  and  in- 
testinal catarrh  for  the  former ;  or  redness  of  the  throat,  or 
cutaneous  and  lingual  desquamation  for  the  latter.  The  fe- 
ver, or  at  least  the  febrile  paroxysm,  should  be  absent  at  the 
time  the  eruption  appears.  While  these  conditions  should 
not  inspire  absolute  confidence,  for  scarlatina,  especially,  pre- 
sents in  its  appearance  and  course  irregularities  more  or  less 
unexpected,  they  are,  nevertheless,  quite  important  elements 
of  probability.  If  one  could  establish  the  previous  existence 
of  the  eruptive  fever  by  which  the  exanthema  shows  itself,  or 
if  one  knew  that  the  patient  had  had  later  the  fever  in  ques- 
tion, there  would  then  be,  at  least  respecting  scarlatina,  a  cer- 
tainty almost  complete.  In  one  case  cited  by  See,  one  was 
able  to  verify,  six  months  after  a  diphtheritic  scarlatiniform 
rash,  the  appearance  of  a  veritable  scarlatina.  Conversely,  in 
a  patient  attacked  with  diphtheria,  supervening  on  the  tenth 
day  of  a  case  of  measles,  I  observed  the  same  day  of  the  for- 
mation of  false  membranes  a  rubeoliform  eruption.  Now,  while 
the  balsams  are  quite  largely  employed   in   the  treatment  of 


150  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

diphtheria,  one  should  bear  in  mind,  in  patients  so  treated,  the 
possibihty  of  a  copaivic  eruption.  In  taking  account  of  these 
various  causes  of  error  we  considerably  reduce  the  number  of 
eruptions  really  due  to  diphtheria.  In  the  large  number  of 
observations  which  I  have  examined  I  have  found  the  exan- 
themata in  only  one-fiftieth  of  the  cases.  They  have  assumed 
various  types.  The  most  common  has  been  the  scarlatini- 
form,  the  only  one  that  See  had  first  in  view.  Others  follow 
which  present  all  the  physical  characteristics  of  measles,  eryth- 
ema limited  to  the  trunk  or  the  extremities,  or  generalized, 
urticaria,  ecthyma,  etc.  Sometimes  they  are  vesicular.  These 
eruptions  have  appeared  from  the  first  to  the  seventh  day  of  the 
disease,  and  from  the  second  to  the  third  day  after  admission 
to  the  ward,  when  the  patients  were  observed  at  hospital. 
These  limits  have  very  rarely  been  exceeded.  Their  duration 
was  always  short,  a  day  or  two  at  most.  They  were  never 
ushered  in  by  general  symptoms.  The  fever,  or  the  increase 
of  the  febrile  movement  already  existing,  the  vomiting,  ano- 
rexia, pruritus  and  tumefaction  failed.  It  is  difficult  to  state 
the  value  of  these  eruptions  respecting  the  prognosis.  See 
admits  that  they  exercise  a  favorable  influence ;  children  who 
had  them  recovered  in  the  proportion  of  two  to  three.  It  ap- 
pears really,  at  first  thought,  that  they  are  observed  most  fre- 
quently in  cases  of  benign  diphtheria.  Respecting  the  scarla- 
tiniform  eruption  the  proportion  is  true ;  the  proportion  of  re- 
coveries was  exactly  two  in  three.  In  the  erythematous  form 
there  was  but  one  death  in  five  cases.  But  in  the  rubeolar 
form  the  number  of  deaths  was  equal  to  that  of  recover>\ 
Finally,  in  the  cases  in  which  the  exanthema  assumed  the  form 
of  urticaria,  the  termination  was  always  fatal.  The  cutaneous 
manifestations,  therefore,  must  be  of  favorable  prognosis. 
While  completely  harmless  of  themselves,  they  accompany 
many  of  the  grave  cases,  and  their  number  would  be  much 
greater  if  the  disease  did  not  very  frequently  run  such  a  rapid 
course  as  to  leave  no  time  for  their  development.  One  will 
approximate  the  truth  more  nearly  by  according  to  them 
a   quite    limited     value    in    this    respect.     From    what    pre- 


GENERAL    DISCRIPTION    OF    DIPHTHERIA.  I51 

cedes  one  may  conclude  that  exanthemata  are  observed  during 
the  course  of  diphtheria  which  appear  to  be  true  cutaneous 
manifestations  of  the  disease ;  that  these  eruptions  are  rela- 
tively infrequent ;  that  they  are  met  with  as  well  in  the  grave 
cases  as  in  the  slight,  and  that  their  appearance  does  not 
modify  the  development  of  the  process. 

Gastro-intestinal  Disturbances. 

These  are  not  common  in  diphtheria  unless  they  should  be 
the  result  of  active  treatment  by  emetics,  and  especially  anti- 
mony. However,  P.  Wilson  believes  that  diphtheria  is  always 
consecutive  to  a  disease  of  the  stomach  ;  Eisenmann,  who  re- 
produced his  work,  thinks  he  has  observed  in  the  great  epi- 
demics of  Paris,  Boulogne  and  Crowfort,  in  England,  that  gas- 
tro-intestinal symptoms  always  preceded  angina.  To  contend 
is  useless. 

In  a  certain  number  of  cases  the  appetite  and  thirst  present 
nothing  worthy  of  note ;  they  follow  the  course  of  the  fever, 
but  generally,  in  the  course  of  angina,  as  in  croup  after  trache- 
otomy, from  the  fact  of  the  disease  itself,  as  well  as  from  the 
restraint  of  deglutition,  anorexia  is  absolute,  and  the  patients 
would  die  if  not  constrained  to  eat  even  by  compulsion.  Bre- 
tonneau  and  Trousseau  especially  have  strongly  insisted  upon 
this  aversion  for  nourishment  and  upon  the  necessity  of  re- 
lieving it. 

Diarrhoea  is  not  very  frequent,  and  very  frequently  it  is  found 
to  arise  from  the  excessive  administration  of  emetics,  es- 
pecially that  of  tartar  emetic.  It  is  not  rare,  under  these  cir- 
cumstances, that  it  assumes  the  choleraic  aspect.  However,  it 
may  exist  without  this  cause.  It  is  found  in  the  prodromes 
and  at  the  moment  of  invasion;  but  under  these  circumstances 
it  appears  to  have  not  much  importance  ;  but  when  it  super- 
venes in  the  course  of  the  disease  it  coincides  nearly  always 
with  other  signs  of  intoxication,  and  ends  in  giving  to  the  pa- 
thological whole  an  unquestionable  stamp  of  gravity.  Under 
other  circumstances,  when  the  economy  is  greatly  enfeebled 
and  when  the  patient  sinks  into  a  complete  cachexia,  diarrhoea 


152  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

intervenes  and  is  classed  with  the  final  phenomena.  The  ex- 
creted matters  generally  present  nothing  of  special  character. 
In  cases  in  which  the  diarrhoea  coincides  with  a  well-marked 
state  of  poisoning,  they  are  very  fetid;  sometimes,  indeed, 
they  are  sanguinolent.  Pseudo-membranous  debris  may  be 
encountered  in  them  without  it  being  easy  to  decide  their  ori- 
gin. Do  they  indicate  exudation  of  false  membrane  in  the 
oesophagus,  stomach,  or  intestines?  Should  they  be  consid- 
ered simply  as  swallowed  after  having  been  detached  from  the 
throat?  The  rarity  of  diphtheritic  exudation  upon  the  lower 
portions  of  the  digestive  tube  would  incline  one  to  the  second 
hypothesis.  However,  when  they  are  very  abundant,  and 
especially  when  they  are  accompanied  by  sanguinolent  ex- 
cretions per  anum,  one  may  suppose  that  they  are  formed  in 
the  intestine.  Vomiting  is  quite  common ;  is  noticed  in  the 
prodromes ;  is  seldom  repeated,  and  is  not  of  unfavorable 
prognosis.  Sometimes,  also,  it  is  due  to  the  treatment  by  tar- 
tar emetic ;  and  it  is  then  associated  with  very  serious  diar- 
rhoea, and  is  sometimes  uncontrollable.  It  is  observed,  also, 
during  the  course  of  the  disease,  especially  in  croup,  a  short 
time  after  the  operation.  It  is  nearly  always,  in  this  case, 
either  the  consequence  of  the  administration  of  emetics  or  the 
indication  of  some  impending  complication :  pneumonia, 
eruptive  fever,  etc.  It  then  decidedly  darkens  the  prognosis. 
Ormerod  regards  frequent  vomiting  as  a  serious  symptom, 
particularly  at  the  time  when  the  throat  begins  to  clear  off. 
He  mentions  some  cases  in  which  gastric  disturbances,  super- 
vening during  convalescence,  are  said  to  have  induced,  in  the 
same  way  as  unusual  intellectual  or  muscular  effort,  a  serious 
collapse  and  sudden  death. 

Gangrene. 

The  fundamental  process  of  diphtheria  is  different  from  gan- 
grene. Agreeing  with  Bretonneau  and  the  French  school,  I 
have  defended  this  doctrine  against  the  modern  German 
school.  But  I  have  also  shown  that  Bretonneau  went  too  far 
in   excluding  gangrene   entirely.     An  extreme   degree   of  in- 


GENERAL    DISCRIPTION    OF    DIPHTHERIA.  1 53 

flammation  and  the  septic  nature  of  diphtheria  appear  to  me  to 
explain  sufficiently  the  formation  of  these  eschars.  Diphthe- 
ria, like  other  diseases  which  frequently  affect  nutrition,  as  ty- 
phoid fever,  measles,  scarlatina,  variola  and  cholera,  act  as 
predisposing  causes;  the  local  inflammations  find  a  soil  fully 
prepared.  If  the  reaction  be  in  the  least  violent  the  vitality  of 
the  tissues  is  destroyed  and  sphacelus  is  produced.  In  the 
majority  of  cases  the  eschar  is  observed  at  the  point  where  the 
inflammation  has  acted  with  the  greatest  intensity ;  thus  the 
tonsils,  the  uvula  and  the  pharynx  are  the  sites  of  election. 
When  an  external  cause  is  added  to  the  above  the  determina- 
tion of  gangrene  receives  thereby  an  additional  impulse.  Such 
is  the  influence  of  compression  exercised  by  the  canula  upon 
the  wound  of  tracheotomy  and  upon  the  mucous  membrane  of 
the  trachea.  It  follows  also  cutaneous  diphtheria ;  in  this  re- 
lation the  vesicular  or  pustular  eruptions,  such  as  herpes  and 
impetigo,  constitute  a  very  manifest  predisposition.  The 
lungs  themselves  may  be  attacked ;  broncho-pneumonia  is 
then  the  exciting  cause.  In  some  cases  gangrene  manifests 
itself  in  several  places  at  once,  or  successively.  The  general 
alteration  of  nutrition  appears  to  me  to  explain  sufficiently  this 
diffusion.  Is  it  necessary  to  invoke  capillary  emboli  ?  The 
state  of  science  does  not  allow  of  a  categorical  answer. 
Briefly,  gangrene  finds  in  diphtheria  the  way  prepared ;  every 
cause  which  diminishes  locally  the  vitality  of  the  tissues :  in- 
flammatory impetus,  compression  and  eruptions,  act  as  deter- 
mining causes.  The  points  of  the  body  where  gangrene  is 
seen  most  frequent  are :  the  tonsils,  the  uvula,  the  pharynx, 
the  soft  palate,  the  lips,  the  trachea,  the  larynx,  the  lungs,  the 
integument  and  the  wound  of  the  tracheotomy.  As  material 
lesions,  those  of  the  lungs  excepted,  it  has  no  great  impor- 
tance, for  it  rarely  produces  any  great  destruction,  but  it  is  of 
no  less  serious  prognosis  when  it  is  spontaneous,  because  it  is 
the  index  of  a  profound  intoxication,  a  grave  alteration  of  nu- 
trition. Thus  it  is  not  encountered  only  in  the  most  severe 
forms.  Gangrene  of  the  wound  following  tracheotomy,  and 
ulcerations  of  the  trachea,  present  a  diminished  importance, 
because  pressure  must  add  greatly  to  the  general  cause. 


154  diphtheria,  croup  and  tracheotomy. 

Disturbances  of  Circulation. 

HcEmorrliage. — This  is  observed  in  diphtheria  as  in  the  ma- 
jority of  infectious  diseases ;  there  it  is  common.  It  occurs 
from  the  mucous  membranes  indiscriminately  and  from  the 
skin.  The  alteration  of  the  blood  and  of  the  walls  of  the  ves- 
sels furnish  a  satisfactory  explanation  of  it.  Therefore,  it  oc- 
curs not  only  when  the  way  to  it  is  opened  by  a  solution  of 
continuity  of  the  tissues,  viz.,  the  wound  in  tracheotomy,  fall- 
ing off  of  the  false  membranes,  separation  of  the  eschars,  but 
also  in  cases  in  which  the  internal  and  external  teguments  ap- 
pear healthy  at  the  point  where  it  occurs.  Thus,  epistaxis  ap- 
peared in  many  cases  during  the  prodomes ;  for  example, 
when  as  yet  no  false  membrane  was  found  in  the  nose. 

The  most  frequent,  without  doubt,  is  epistaxis.  Then  follow 
those  occurring  in  the  throat  at  the  point  whence  arise  the 
false  membranes.  In  this  locality  it  sometimes  constitutes 
only  oozing,  so  slight  as  not  to  be  perceived  from  without,  but 
which  infiltrates  the  false  membranes  and  colors  them  brown. 
While  admitting  those  which  occur  at  the  time  of  the  opera- 
tion, the  wound  is  also  the  site  of  frequent  haemorrhages.  I 
have,  in  a  former  wcrk,  indicated  that  one  may  observe  them 
until  the  eleventh  day.  We  should  also  note,  in  the  order  of 
frequence,  those  which  arise  from  the  surface  of  the  gumg, 
lips,  or  from  the  nose  and  throat,  at  the  same  time.  There  are, 
finally,  those  which  have  their  seat  in  the  skin  or  sub-cutane- 
ous connective  tissue  ;  they  present  themselves  in  the  form  of 
purpura,  or  ordinarily  of  ecchymoses  of  limited  extent.  Green- 
how  cites  a  fatal  case  of  hsematemesis  in  the  course  of  diph- 
theria in  a  boy  sX.  15.  Lespine  reports  a  similar  case.  While 
often  occurring  but  once,  haemorrhage  may  recur  several  times 
either  on  the  same  day  or  on  several  successive  days,  or  at 
lono-er  intervals.  It  may  be  repeated  five  or  six  times.  It 
may  also  occasion  an  almost  continuous  oozing.  In  quantity 
it  is  often  moderate,  sometimes  very  moderate  each  time.  But 
it  does  happen  that  the  sanguinolent  exhalation  assumes  un- 
pleasant proportions,  and  that  we  are  obliged  to  resort  to 
plugging  the  nasal  fossae  or  to  the  application  of  perchloride 


GENERAL    DISCRIPTION    OF    DIPHTHERIA.  1 55 

of  iron  to  the  throat.  I  know  of  only  one  case  of  alarming 
haemorrhage,  and  I  shall  speak  of  it  later.  The  beginning  of 
the  disease,  that  is  the  period  embraced  between  the  initial 
symptoms  and  the  fifth  or  sixth  days,  is  the  date  of  most  fre- 
quency for  haemorrhages.  Then  they  are  observed  from  the 
seventh  to  the  fourteenth  day,  the  latest  date  that  I  have  not- 
ed. This  predilection  of  haemorrhages  for  the  early  days  of 
the  disease  is  not  astonishing  when  one  reflects  that  they  are 
always  the  index  of  very  serious  cases  of  short  duration.  They 
are,  really,  in  diphtheria,  formidable  symptoms  from  the  con- 
dition of  profound  intoxication  which  they  represent.  They 
are  the  necessary  accompaniments  of  infectious  and  malignant 
cases.  Epistaxis,  that  particularly  which  arises  during  the  pro- 
dromes, or  just  at  the  onset,  before  the  appearance  of  false 
membranes,  is  that  form,  the  influence  of  which  is  the  most 
deleterious.  Those  which  appear  only  at  the  time  of  the  sep- 
aration of  the  false  membranes  from  the  seventh  to  the  four- 
teenth day,  have  a  less  serious  significance.  In  25  cases  of 
early  epistaxis,  death  occurred  in  20;  in  ii  cases  of  later  epis- 
taxis it  occurred  in  8.  Haemorrhage  trom  the  mouth  and 
from  the  throat,  or  simply  constant  oozing  from  these  parts, 
are  of  quite  unfavorable  prognosis;  14  deaths  in  15  cases.  A 
boy  aet.  4  1-2  years,  admitted  to  the  hospital  on  the  twelfth 
day  of  a  diphtheritic  angina,  with  coryza,  presented  a  contin- 
ual sanguinolent  oozing  from  the  throat,  nose  and  lips ;  on  the 
sixteenth  day  the  haemorrhage  assumed,  suddenly,  such  a  de- 
gree that  the  patient  succumbed  in  a  few  minutes.  It  is  the 
same  with  sanguineous  exudations,  scarcely  visible,  which  in- 
filtrate the  false  membranes ;  death  occurred  in  every  case. 
Haemorrhage  from  the  wound  presented  a  serious  significance, 
although  a  little  less.  In  7  cases  arising  in  the  first  few  days, 
5  died ;  in  7  cases  observed  later,  5  died.  Sub-cutaneous 
haemorrhages,  as  well  as  purpura,  are  of  no  better  prognosis. 
Haemorrhage  is  therefore  an  extremely  grave  prognostic  in 
diphtheria,  not  from  its  abundance,  which  is  nearly  always 
moderate,  but  because  it  is  a  sure  index  of  malignancy.  It  is 
so  much  the  more  formidable  as  it  approaches  to  a  period 
nearer  to  the  beginning. 


156  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

CEdema. — Independently  of  that  which  pertains  to  albumi- 
nuria, we  sometimes  encounter  in  the  course  of  diphtheria, 
oedema  localized  or  generalized,  which  coincides  with  normal 
urine.  The  former  have  been  seen  from  the  fifth  to  the  ninth 
day  of  diphtheritic  angina  following  scarlatina ;  it  is  probable 
that  it  had  its  starting  point  in  this  eruptive  fever.  The  other, 
which  alone  should  engage  us,  is  free  from  this  origin.  At  one 
time  it  is  limited  to  the  face  or  upper  extremities,  at  another 
it  is  general  and  should  be  called  anasarca.  Its  appearance 
is  late ;  it  occurs  from  the  eighteenth  to  the  twentieth  day 
from  the  invasion;  it  is  of  short  duration,  and  terminates 
nearly  always  in  recovery,  at  least  when  other  complications 
do  not  supervene.  What  is  its  cause  ?  We  might  refer  to 
cold,  but  this  has  not  been  noted.  Must  we  recognize  in  its 
pathogenesis  a  paralysis  of  the  vaso-motors  ?  This  mechan- 
ism, indicated  by  several  authors,  has  been  placed  beyond 
doubt  by  Ranvier.  The  action  of  diphtheria  upon  the  nervous 
system  is  so  evident,  so  common,  that  one  might  admit  with- 
out much  difficulty  the  extension  of  this  action  to  the  system 
of  the  great  sympathetic. 

Endocarditis. — From  the  examination  and  the  discussion  of 
facts  which  have  been  presented  to  prove  the  anatomical  ex- 
istence of  endocarditis  in  diphtheria,  I  must  conclude  that 
this  lesion  is  much  less  common  than  announced  by  John 
Bridger,  Bouchut  and  L.  Lagrave.  Let  us  see  what  the  ex- 
amination of  the  patient  teaches  us.  I  take  the  signs  of  endo- 
carditis to  be  such  as  L.  Lagrave  gives  them.  They  are : 
I.  Force  and  fulness  joined  with  irregularity  and  rapidity  of 
the  cardiac  contractions.  2.  Increased  area  in  which  the  im- 
pulse of  the  heart  is  perceptible.  3.  Bruit  de  souffle  usually  sys- 
tolic, and  localized  towards  the  apex  of  the  heart.  This  lat- 
ter, says  the  author,  is  the  most  valuable  of  these  signs,  and 
we  may  add,  the  only  one  which  is  certain.  Now,  what  diffi- 
culties has  one  not  experienced  in  examining  the  heart  when 
it  is  agitated  by  croup?  The  oppression,  the  anguish,  and  the 
restlessness  of  the  patient  fully  explain  the  disturbance  of  the 
heart's  action.     The   laryngotracheal  wheezing,  its  reverbera- 


GENERAL    DISCRIPTION    OF    DIPHTHERIA.  1 57 

tion  in  the  chest,  strongly  obscure  the  bmit  de  souffle.  If  the  ex- 
amination be  made  after  tracheotomy  one  finds  the  same  obsta- 
cles in  the  metallic  and  strididous  sound  which  the  air  produces 
in  passing  through  the  canula,  and  in  the  gurgling  produced 
in  the  interior  of  this  instrument  when  it  is  obstructed  with  the 
products  of  expectoration,  without  counting  the  rales  of  vari- 
ous kinds  and  the  bronchial  souffle  which  are  the   expression 
of  the  very  frequent  pulmonary  complications  in  croup.     Thus 
it  is  explained,  that  in  the  majority  of  cases  L.  Lagrave  failed 
to  note  the  souffle,  and  that  in  others  he   found   doubtful  mur- 
murs and  very  slight  prolonging  of  the  first  sound,  but  none  of 
the  frank,  rough  murmurs   which   render   endocarditis  unques- 
tionable.    In  47  cases,  in  which  the  autopsy  presented  lesions 
which  L.  Lagrave   referred   to   endocarditis,  the   murmur  had 
been  observed  only  6  times,   and  often   with   equivocal   char- 
acteristics.    There  was  nothing  surprising  in  this  result   when 
the  real  anatomical  value  of  these  lesions  is  understood.     Yet, 
one  might  take  exceptions   to   the  significance  of  the  cardiac 
murmur  (souffle)  recognized   under  these   circumstances;  and 
one  should  be  ce  certain  that  it  did   not   exist  anterior  to  the 
diphtheria.     Angina   without   croup  and  cutaneous  diphtheria 
are  more  favorable  to  the  perception  of  the  cardiac  symptoms ; 
the  restlessness  of  the  patient  is  less,  the   oppression  is  gener- 
ally null,  and  pulmonary  complications  are  uncommon.    How- 
ever, in  5  cases   of  diphtheritic   angina,  cited  by  the  same  au- 
thor, the  murmur  was  observed   in  but  2  cases.     We   see  how 
rare  are  the  cases  which,  in  this  series  of  observations,  so  ably 
made  and  presented  as  arguments  in  support   of  the   propo- 
sition, may   be   regarded    as   convincing.     John   Bridger,  who 
reported  lOi  cases  of  endocarditis,  observed  the  systolic  mur- 
mur (souffle)  in  only  4  cases.     How  does  he   demonstrate  the 
existence  of  endocarditis  in  the  others  ?     My  personal  investi- 
gations  are  absolutely  negative.     Observations  of  diphtheria 
to  the  number  of  149,  taken  in  these  later  years,  since  the  ap- 
pearance of  the   works  of  Bouchut  and  L.  Lagrave,  have  not 
furnished  a  single  case  of  endocarditis.     I  should  fear  to   ex- 
press myself  in  such  a  positive  manner  if  I  should  trust  to  the 


158  DIPHTHERIA,    CROUP    AND    TRACHEOTOMV. 

single  testimony  of  my  senses,  but  a  large  number  of  these 
patients  were  auscultated  also  by  Barthez  and  by  d'Espine 
and  Gombault,  his  assistants ;  there  was  never  any  difference 
as  to  the  result  of  the  examination.  The  conclusion  of  this 
chapter,  therefore,  is  that  diphtheritic  endocarditis,  while  be- 
ing admissible  by  analogy,  is  extremely  rare,  as  pathological 
anatomy  and  clinical  observation  alike  demonstrate. 

Grave  Disturbances  of  the  Exdo-cardial  Circulation. 

Thrombosis.  Sudden  Death.  —  Closely  connected  with  the 
disturbances  of  the  general  circulation,  viz.,  haemorrhages  and 
oedema,  one  has  noted  in  the  course  of  diphtheria,  particularly 
during  convalescence,  the  occurrence  of  very  serious  symp- 
toms, nearly  always  fatal,  and  which  appear  to  have  their  seat 
in  the  cavities  of  the  heart.  Richardson,  Beau,  Gerlier,  Meigs, 
Duchenne  of  Boulogne,  L.  Lagrave  and  Beverly  Robinson 
have  insisted  upon  their  frequency.  These  phenomena  follow 
either  a  rapid  or  a  slow  course.  In  the  first,  when  the  false 
membranes  have  disappeared,  and  convalescence  appears 
established,  the  patient  is  suddenly  seized  with  praecordial  dis- 
tress, and  he  complains  of  terrible  oppression  in  the  same  re- 
gion and  at  the  same  time  with  extreme  dyspnoea.  The  coun- 
tenance is  changed,  the  eyes  are  expressive  of  deep  anxiety, 
and  a  general  pallor  covers  the  body.  Cyanosis  has  never 
been  noticed ;  in  contrast  to  many  other  cases,  in  which  death 
occurs  from  the  heart,  there  is  no  tendency  to  asphyxia,  but  to 
syncope.  The  extremities  first  become  cold,  then  the  whole 
body.  Cutaneous  sensibility  is  preserved.  The  patient  is 
restless;  under  the  control  of  a  veritable  jactitation,  he  is  con- 
stantly moving  about ;  it  is  with  difficulty  he  can  be  kept  on 
his  bed,  and  the  hands  are  constantly  thrown  from  under  the 
covers.  He  appears  to  struggle  in  spite  of  his  weakness. 
The  adult  has  the  impression  of  approaching  death,  and  bids 
farewell  to  his  friends.  Respiration  is  frequent,  but  ausculta- 
tion proclaims  no  abnormal  sound;  sometimes  the  respiratory 
murmur  assumes  more  of  the  puerile  tone.  The  pulse  is 
small,    irregular,   unequal;  it  soon  becomes  thready;  its  fre- 


GENERAL    DISCRIPTION    OF    DIPHTHERIA.  1 59 

quency  is  moderate ;  it  rarely  exceeds  80  to  100  pulsations  per 
minute ;  more  frequently  it  slackens  and  falls  to  50  or  40  pul- 
sations; in  one  case  it  beat  not  more  than  26.  The  sounds  of 
the  heart  present  the  same  irregularities ;  they  are  feeble, 
muffled  and  deep.  This  weakness  increases  progressively  and 
the  patient  expires  quietly  at  the  close  of  a  period  varying 
from  one  to  several  hours,  if  he  is  not  suddenly  carried  off  by 
syncope.  Examination  of  the  heart  gives  no  information. 
Ordinarily  the  blowing  sound  is  not  heard.  The  praecordial 
dullness  remains  normal.  When  the  course  of  these  symptoms 
is  slow,  the  general  aspect  is  the  same ;  the  duration  only  dif- 
fers. In  the  beginning  the  strength  is  still  preserved  and  the 
patient  moves  easily  in  his  bed ;  exhaustion  comes  on  only  to- 
wards the  close.  Pallor,  general  coldness  and  jactitation  are 
also  decided.  The  cardiac  murmurs  are  confused,  disturbed, 
and  appear  paroxysmal ;  slight  blowings  have  been  noticed  in 
some  very  rare  cases.  Respiration  is  often  interrupted  with 
long  and  moaning  sighs,  quite  like  those  in  tubercular  menin- 
gitis. The  intellect  preserves  its  integrity.  Death  occurs  at 
the  end  of  two,  three,  or  even  seven  days,  as  in  a  case  cited  by 
Meigs,  in  consequence  of  progressive  debility,  or  suddenly  in 
syncope.  These  symptoms  are  rare.  They  seldom  appear  at 
the  beginning  of  the  disease,  but  from  the  tenth  to  the  twenty- 
first  day,  during  established  convalescence,  when  all  local  or 
general  symptoms  have  disappeared.  In  one  case,  however, 
they  made  their  appearance  on  the  sixth  day.  Authors,  wit- 
nesses of  these  facts,  have  explained  them  by  the  formation 
of  clots  in  the  heart,  or  cardiac  thrombosis.  This  theory  is 
open  to  important  objections.  I  have  shown  that  the  coagula 
found  under  these  circumstances  have  none  of  the  character- 
istics assigned  to  clots  formed  during  life,  by  authors  who  have 
treated  the  subject  with  ability.  Besides,  these  same  concre- 
tions are  met  with  in  a  large  number  of  subjects  dead  of  dis- 
eases very  different,  and  in  which  cardiac  symptoms  have  been 
absent.  Adding,  then,  that  they  are  nearly  always  accompa- 
nied, in  subjects  dead  of  diphtheria,  by  serious  pulmonary 
lesions,  one  cannot,  however,   demonstrate  a  probable  patho- 


l6o  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

genetic  relation  between  these  products  and  tlie  cardiac  symp- 
toms of  diphtheria.  How  then  shall  we  explain  these  phe- 
nomena, so  remarkable  ?  We  cannot  deny  that  they  have 
their  point  of  departure  in  the  heart.  The  praecordial  distress, 
the  varieties  of  the  pulse,  the  tendency  to  syncope,  the  cardiac 
palpitation,  indicate  this  in  a  positive  manner.  The  obstacle 
which  presents  itself  to  the  contractions  of  the  heart,  not  being 
found  in  the  cavity  of  the  organ,  it  must  be  sought  then  in  its 
walls.  Myocarditis  and  the  degeneration  which  follows  it 
have  greatly  prepossessed  several  authors,  who  attribute  to  it 
great  importance  in  the  formation  of  clots,  in  consequence  of 
the  feebleness  of  the  contractions  which  resulted  from  it.  This 
influence  is  very  acceptable  in  theory ;  however,  it  is  proper  to 
observe  that  myocarditis  is  rare,  and  that  it  is  ordinarily  local- 
ized and  incapable  of  exercising  any  considerable  influence 
upon  the  contractions  of  the  heart.  By  a  singular  coincidence 
in  the  cases  in  which  it  has  been  found  on  autopsy,  the  clots 
were  absent  or  without  vital  characteristics ;  and  no  cardiac 
symptoms  had  been  noticed  before  death.  If  myocarditis  is  a 
factor  in  the  mechanism  of  enfeeblement  and  arrest  of  the 
heart,  it  must,  therefore,  elucidate  all  the  cases. 

The  only  explanation  which  can  be  offered  is,  by  exclusion, 
diplitheritic  paralysis.  Thus,  as  I  shall  show  in  treating  of  this 
important  perturbation  of  the  nervous  system,  a  great  number 
of  authors  have  described,  supporting  themselves  by  authentic 
observations,  the  cardiac  disturbances  which  accompany  it. 
These  symptoms  are  identical  with  those  which  are  given  as 
arising  from  cardiac  thombosis;  moreover,  they  appear  from 
the  tenth  to  the  twenty-first  day,  at  the  period  when  diphthe- 
ritic paralysis  prevails.  The  action  of  paralysis  in  the  patho- 
genesis of  cardiac  symptoms  attributed  to  thrombosis,  appears, 
therefore,  very  plausible.  These  conditions,  so  favorable  and 
so  frequent,  especially  so  far  as  the  second  is  concerned,  viz., 
myocarditis  and  paralysis  of  the  cardiac  fibres,  render  the  for- 
mation of  clots  at  a  date  just  before  death  not  so  common  as 
one  might  think.  This  rarity  is  anatomically  demonstrated. 
In  the  same  cases  in  which  we  might  admit  that  coagulation 


GENERAL    DISCRIPTION    OF    DIPHTHERIA.  l6l 

is  formed  during  life  we  must  recognize  that  it  has  been  purely 
passive. 

Convulsions. 

Eclamptic  paroxysms  are  very  rare  symptoms  in  diphtheria. 
They  generally  appear  to  have  no  special  relation  to  diphthe- 
ria, particularly  when  they  supervene  at  the  beginning  of  the 
disease.  Convulsions  are  anything  but  rare  in  children,  par- 
ticularly at  the  initial  period  of  acute  diseases,  whatever  they 
may  be.  Physicians  who  are  acquainted  with  infantile  pa- 
thology understand  this  peculiarity.  They  appear,  therefore, 
sometimes  at  the  beginning  of  either  benign  or  malignant 
diphtheria,  as  in  all  other  diseases ;  they  have  no  influence 
upon  the  prognosis.  Others  manifest  themselves  after  trache- 
otomy ;  I  shall  speak  of  them  at  the  same  time  as  of  the  se- 
quences of  this  operation. 

Diphtheritic  Paralysis. 

The  paralytic  phenomena  which  appear  during  the  course 
of  diphtheria  or  during  convalescence  therefrom  have  been 
recognized  or  suspected  from  the  remotest  antiquity.  Hippo- 
crates in  Book  VI.  of  Epidemics,  Coelius  Aurelianus,  Marcus 
Aurelius  Severinus  (1641),  and  Bellini  at  about  the  same  pe- 
riod, gave  vague  hints  of  it.  They  are  found  clearly  pointed 
out  in  the  writings  of  Nicolas  Lepois  (1580),  of  Ghisi  (1747),  of 
Miguel  Heredia  (1690),  of  Chomel  (1749),  of  Marteau  de 
Grandvilliers  (1767),  of  Samuel  Bard  (1784),  of  Jurine  (1809)  of 
Albers  of  Bremen  (1809),  of  Bretonneau  and  of  Rilliet.  The 
question  was  not  thoroughly  investigated  until  after  the  disser- 
tation of  M.  Maingault.  The  impulse  given  at  that  time  gave 
rise  to  numerous  works  of  which  the  principal  ones  were  those 
of  Roger,  See,  Trousseau,  Gubler,  Colin,  Charcot  and  Vul- 
pian,  Lallement,  Billard,  Perate,  Tavignot,  Foucher,  Hermann 
Weber,  Ormerod,  Brenner,  Tille,  Ravn,  David  Easton,  Kraft 
Ebing,  Oertel,  Rosenthal,  Greenhow,  Wade,  Paterson,  Roger 
and  Peter,  Lorain  and  Lepine,  Bailly,  Mansord  and  Duchenne. 

Paralytic  troubles  appear  most  commonly  during  convales- 
cence,   and    from   eight  to  fifteen   days   after  recovery,  that 


1 62  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

limit  perhaps  extending  to  thirty  days.  They  may  show 
themselves  sooner,  in  which  case  they  are  manifest  during  the 
local  development  of  diphtheria,  from  the  fifth  to  the  eleventh 
day  from  its  onset,  and  sometimes  even  from  the  second  or 
third  day. 

If  they  appear  at  a  late  period,  when  they  do  appear  their 
manifestations  in  the  several  systems  develop  without  inter- 
ruption. If,  on  the  contrary,  they  come  early,  it  is  not  rare  to 
see  them  ceasing  after  a  short  time  to  recur  at  a  period  more 
or  less  remote  and  under  another  form. 

Their  onset  may  be  free  from  general  symptoms,  yet  it  is 
quite  often  announced  by  fever  or  by  the  appearance  or  re- 
currence of  albuminuria. 

When,  during  convalescence  from  diphtheria,  the  thermic 
curve  is  observed  to  suddenly  rise  again,  paralysis  is  one  of 
the  imminent  complications. 

Every  apparatus  is  subject  to  diphtheritic  paralysis.  Noth- 
ing is  more  capricious,  more  unforeseen,  than  its  extension,  or 
than  the  variations  in  its  distribution. 

Though  often  limited  to  a  single  organ,  it  may  involve  one 
or  several  of  them.  Finally,  in  other  cases  it  extends  to  the 
whole  organism. 

Its  place  of  election  and  the  site  to  which  it  is  usually  lim- 
ited is  the  velum  palati  to  which  should  be  added  the  upper 
portion  of  the  larynx.  The  latter  region  is  often  the  only  one 
affected,  and  that  almost  always  before  the  velum  palati ;  the 
patient  coughs  at  the  instant  of  deglutition  because  of  con- 
tact of  food  with  the  mucous  membrane  of  the  laiynx.  When 
tracheotomy  has  been  performed  particles  of  food  pass 
through  the  wound  or  the  canula.  After  a  few  days  the  cough 
takes  on  a  dull  stifled  sound. 

Paralysis  of  the  velum  palati  is  marked  at  first  by  a  nasal 
intonation — speech  is  slow,  articulation  of  sounds  is  difficult, 
and  more  or  less  loud  snoring  is  heard  during  sleep.  At  the 
same  time  deglutition  becomes  much  embarrassed.  Drinks  or 
liquid  foods  are  expelled  through  the  nose.  Solid  substances 
only  can  pass,  and  that  when  they  form  a  bolus  of  some  size. 


GENERAL    DISCRIPTION    OF    DIPHTHERIA.  163 

When  the  pharynx  is  affected  at  the  same  time,  swallowing  of 
food  becomes  far  more  difficult ;  it  engages  at  times  in  the 
air-passages  at  the  risk  of  causing  the  grave  accident  of  suffo- 
cation.    Solid  food  may  also  be  rejected. 

To  the  danger  of  suffocation  is  added  that  of  inanition.  The 
rejection  of  food  soon  inspires  a  real  horror  of  taking  nourish- 
ment. If  the  mouth  of  the  patient  is  opened  it  is  seen  that 
the  velum  palati  does  not  retain  its  usual  position ;  it  is  mo- 
tionless and  pendant ;  its  insensibility  is  evident,  and  tickling 
the  mucous  membrane  with  a  feather,  or  even  pricking  it  with 
a  sharp  instrument  does  not  provoke  a  single  reflex  movement. 

At  the  same  time,  with  the  velum  palati,  the  tongue,  the 
lips  and  the  cheeks  may  be  enfeebled.  The  patient  is  then 
unable  to  inflate  the  cheeks,  to  whistle,  to  blow  out  a  candle, 
to  gargle,  or  to  suck.  The  face  is  motionless,  the  lips  allow 
the  saliva  to  dribble  out,  and  the  tongue  is  moved  with  diffi- 
culty. Sometimes  it  hangs  out  of  the  mouth  and  is  the  seat 
of  vibratory  movements.  From  that  condition  arise  troubles 
in  phonation  which  I  shall  review  further  on. 

Paralysis  may  be  limited  to  the  fauces,  but  often  extends  to 
other  apparatus,  and  may  become  general. 

As  it  affects  sensibility  and  the  organs  of  sensation  as  well 
as  motion,  I  shall  describe  separately  the  difficulties  which  it 
brings  to  these  diverse  functions. 

Movement  may  be  enfeebled  in  all  or  a  portion  of  the  mem- 
bers. In  the  first  case  the  lower  limbs  are  first  attacked,  while* 
in  the  second  they  alone  are  usually  affected.  The  patient 
feels  a  tingling  and  a  sense  of  weight  in  the  legs ;  walking  is 
difficult;  ascent  or  descent  of  stairs  is  painful.  Standing  up- 
right necessitates  great  effort  and  becomes  impossible ; 
htretched  upon  his  couch,  the  patient  at  length  no  longer  has 
power  to  lift  his  limbs. 

Rarely  does  the  paralysis  remain  localized  in  the  lower 
limbs ;  on  the  contrary  it  tends  to  involve  the  upper  extrem- 
ities also.  The  arms  are  moved  with  difficulty  ;  grasping  ob- 
jects a  little  heavy  becomes  impossible,  and  tremors  affect  the 
limbs.     The  muscular  force,  measured   by   the   dynamometer. 


164  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

descends  from  the  normal,  which  is  from  50  to  55  kilo- 
grammes, to  20  kilogrammes ;  and  it  even  falls  to  10.  Soon 
the  patient  becomes  absolutely  unable  to  use  his  arms,  and 
must  be  fed  by  an  attendant.  He  can  neither  sit  nor  turn 
himself  in  his  bed.  That  is  not  all.  The  muscles  of  the  neck 
are  affected  in  their  turn  as  well  as  those  of  the  face ;  the  head, 
unsupported,  falls  upon  the  chest,  and  rolls  over  at  the  least 
impulse.  That  attitude,  joined  to  the  immobility  of  the  face, 
stamps  the  patient  with  an  expression  of  hebetude  which  is 
most  striking. 

The  muscles  of  the  trunk,  the  intercostals  and  the  diaphragm 
are  also  attacked.  The  thorax  remains  immovable  ;  the  ab- 
domen is  depressed  or  remains  relaxed  during  inspiration  in- 
stead of  dilating.  The  expiratory  muscles  also  sometimes  be- 
come paretic.  From  this  muscular  debility  there  result  imper- 
fect functional  action  of  the  lungs,  insufficient  haematosis  and  a 
passive  congestion  of  tlie  organs.  The  respiration  is  panting, 
the  patient  experiences  a  feeling  as  of  a  foreign  body  in  the 
chest,  bronchial  mucus  accumulates,  cyanosis  appears  in  the 
extremities  and  on  the  mucous  surfaces,  and  asphyxia  becomes 
imminent.  Post-mortem  examination  shows  that  to  this  con- 
dition there  corresponds  a  congestion  of  the  lung  which  may 
extend  as  far  as  splenization.  I  have  also  recognized  in  these 
cases  pulmonary  infarctions,  and  sub-pleural,  sub-pericardial 
and  sub-arachnoid  ecchymoses.  We  can  conceive  the  gravity 
which  the  slightest  lesion  may  assume  when  it  develops  in  a 
lung  so  little  able  to  resist. 

The  heart  itself  does  not  escape  paralysis.  Perate,  Main- 
gault,  Bissel,  Hermann  Weber,  Billard,  Duchenne,  and  Bailly 
have  described  the  cardiac  troubles  which  attract  attention  in 
patients  attacked  with  diphtheritic  paralysis,  viz.,  praecordial 
distress,  small,  slow  and  irregular  pulse,  becoming  at  times 
thready  and  imperceptible. 

Billard,  who  was  able  to  observe  in  his  own  person  this 
whole  series  of  symptoms,  has  given  us  his  sensations  :  "At  the 
moment  when  sensation  began  to  return  to  the  limbs,  cardiac 
palpitation  v/ith  intermittence  and  a  sense  of  suffocation,  made 


GENERAL    DSJKIPTION    OF    DIPHTHERIA.  165 

me  fear  cardiac  paralysis  and  a  complete  arrest  of  the  circula- 
tion." Though  usually  very  serious,  these  complications  may 
be  cured,  as  the  case  of  Billard  and  others  have  proved.  Un- 
fortunately death  is  the  usual  result.  It  is  brought  on  by  the 
progress  of  the  cardiac  debility  which  may  extend  over  a  pe- 
riod of  perhaps  two  days,  or  it  may  seize  the  patient  suddenly 
and  carry  him  off  in  syncope.  Even  in  those  cases  where  it 
comes  on  slowly  death  never  results  from  asphyxia,  but  al- 
ways from  syncope.  I  have  described  this  condition  in  detail 
in  the  chapter  on  cardiac  thrombosis. 

All  these  phenomena,  in  which  we  recognize  the  symptoms 
of  cardiac  paresis,  show  that  the  heart  may  be  attacked  with 
paralysis  as  well  as  the  pharjMix,  the  intestines,  or  the 
eyes.  In  the  larger  number  of  cases  the  debility  affects  the 
heart  after  other  organs,  or  at  the  same  time  with  them.  It  is, 
in  some  sense,  the  final  limit  of  the  extension  of  the  paralysis. 
In  certain  instances  observed  by  Perate  and  Bissell,  to  which 
must  be  added  others  by  Beau  and  Gerlier,  the  heart  alone  was 
paralyzed.  If  this  fact  seem  at  first  surprising  we  should  re- 
member that  paralysis  of  single  organs  is  not  rare  in  diphthe- 
ria. Do  we  not  often  see  the  palate  alone  affected?  If  this 
fact,  by  virtue  of  its  frequency,  does  not  seem  conclusive 
enough,  we  can  adduce  others  cited  by  Loyaute  and  Roger,  in 
which  paralysis  has  attacked  exclusively  regions  usually  ex- 
empt, such  as  the  eye,  the  rectum  and  the  trunk. 

Paresis  limited  to  the  heart  has,  moreover,  some  analogies. 
There  is  no  serious  reason  to  urge  against  what  is  believed  to 
be  the  cause  of  the  cardiac  complications  of  diphtheria 
especially  as  those  disorders  are  observed  during  convales- 
cence, a  period  peculiarly  subject  to  diphtheritic  paralysis.  It 
is  rational  to  attribute  them  to  the  influence  of  a  patholoo-ical 
fact  admitted  on  all  hands,  rather  than  to  cardiac  thrombosis 
the  fact  of  which  is  questionable,  and  which  is  at  least  very 
rare  in  this  connection. 

The  rectum  and  the  sphincter  ani  are  quite  frequently  at- 
tacked. We  then  observe  constipation,  to  which  succeeds  in- 
continence of  fecal  matters.  Debility  of  the  abdominal  mus- 
cles is  another  frequent  cause  of  constipation. 


l66  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY, 

When  the  paralysis  affects  the  bladder  there  are  dysuria  and 
tenesmus.  The  cavity  of  the  viscus  becomes  considerably  di- 
lated, and  micturition  comes  on  only  from  over-distention. 
When  it  affects  the  sphincter  there  is,  on  the  contrary,  incon- 
tinence. 

The  genital  functions  often  experience  the  consequences  of 
diphtheria.  Complications  of  these  organs  are  as  frequent  as 
those  I  have  just  enumerated  are  rare,  and  are  the  result  of 
generalized  paralyses.  They  are  observed  even  in  light  paral- 
yses, and  in  those  that  are  limited  to  the  fauces.  The  diffi- 
culty consists  in  impotence  and  in  complete  loss  of  virile 
power.  Is  anything  analogous  experienced  by  women  ?  If  so 
the  fact  has  not  been  noted. 

The  paralysis  is  usually  symmetrical.  Very  rarely  does  it 
assume  a  hemiplegic  form.  I  have  met,  for  my  part,  one  case 
of  right  hemiplegia.  Even  under  these  circumstances  it  is  ex- 
ceptional that  the  hemiplegia  is  absolute,  that  is  to  say,  that 
the  side  which  seems  well  is  not  weakened  to  a  certain  degree. 
Some  cases  of  facial  hemiplegia  have  been  noted. 

The  changes  in  motility  which  are  met  with  in  diphtheria 
do  not,  according  to  all  authors,  belong  to  true  paralysis. 
Hermann  Weber  observes,  moreover,  an  incoordination  ex- 
pressed by  choreic  movements. 

According  to  Brenner,  the  affections  of  motility  are  of  three 
kinds:  I.  True  ataxia,  caused  probably  by  a  lesion  of  a  centre 
of  coordination  of  movement.  2.  Ataxic  paralysis  character- 
ized by  paresis  of  certain  groups  of  muscles  of  the  extremities 
and  by  complete  paralysis  of  other  groups.  3.  True  paralysis 
which  may  attack  equally  all  the  muscles  of  the  extremities 
and  which  may  be  complete  or  incomplete.  The  inequality  of 
the  paralysis  in  the  different  groups  of  muscles  can,  in  fact, 
give  rise  to  choreic  movements. 

The  action  of  electricity  on  this  form  of  paralysis  has  been 
carefully  studied.  It  has  been  established  that  the  faradic 
contractility  is  lessened  while  the  galvanic  contractility  is 
notably  increased. 

The  affections  of  motility  are   usually   steadfast.     Yet,  they 


GENERAL    DISCRIPTION    OF    DIPHTHERIA.  I67 

may  be  subject  to  curious  variations.  The  paralytic  symptons 
alternate  with  one  another.  They  appear  in  healthy  members 
on  one  day — to  disappear  the  next.  Remissions  and  exacer- 
bations succeed  each  other  without  known  cause,  and  give  rise 
to  a  perpetual  come-and-go.  This  instability  has  attracted  a 
l.Mge  number  of  authors  (Gubler,  Trousseau,  Billard,  David 
Easton,  Weber,  etc.). 

In  its  return  motility  follows  the  same  order  as  in  its  de- 
parture. It  reappears  first  in  the  lower  limbs  and  afterwards 
in  the  upper  extremities,  just  as  after  a  cerebral  lesion. 

Sensation  passes  through  the  same  vicissitudes.  It  is  either 
obtunded  or  abolished.  We  can  verify  and  measure  its  im- 
pairment by  means  of  Weber's  compasses.  Anaesthesia  is  at 
times  accompanied  by  analgesia.  It  may  occupy  the  entire 
cutaneous  surface,  but  is  most  commonly  distributed  like  hys- 
terical paralysis  in  isolated  tracts. 

It  precedes  the  paresis,  and  likewise  begins  at  the  lower 
limbs.  Sometimes  the  upper  extremities  are  alone  affected. 
According  to  Hermann  Weber,  it  should  not  extend  above 
the  elbows  or  the  knees.  This  localization  is  quite  often  ob- 
served, but  it  will  not  do  to  make  it  a  general  law,  as  it  admits 
of  numerous  exceptions. 

Its  onset  is  announced  by  numbness  and  tingling,  proceed- 
ing from  the  toes  up  along  the  limbs,  and  a  certain  sensation 
of  coldness  in  the  feet. 

When  it  attacks  the  lower  limbs  the  patient  experiences 
symptoms  of  plantar  anaesthesia.  He  does  not  feel  the  ground. 
It  seems  to  him  to  sink  under  his  feet.  He  cannot  preserve 
his  balance  except  by  keeping  his  eyes  open.  Walking  in 
the  dark  is  impossible.  When  it  attacks  the  hands  small  ob- 
iects  cannot  be  perceived.  The  tactile  sensibility  of  the  tongue, 
the  lips  and  the  cheeks  is  diminished. 

Exceptionally  the  skin  is  hyperaesthetic.  There  is  found 
also,  at  times,  a  certain  tenderness  on  pressure  along  the  spine. 

The  organs  of  special  sense  are  not  spared. 

The  eyes  often  become  weak.  Dr .  Loyaute  observed  in 
one  case  complete,   though  transient,   blindness.     The  visual 


l68  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

troubles  are  oftenest  limited  to  amblyopia.  Presbyopia  is  fre- 
quent, while  myopia,  on  the  contrary,  is  extremely  rare. 
Trousseau,  however,  speaks  of  a  patient  in  whom  myopia  fol- 
lowed presbyobia.  The  pupils  are  dilated  and  immovable. 
When  one  eye  only  is  affected  there  is  diplopia  and  inequality 
of  the  pupils. 

No  lesion  of  the  media  of  the  eye  or  of  the  retina  has  been 
proven.  It  is  probable,  and  it  is  the  opinion  of  opthalmolo- 
gists  like  FoUin,  Graefe,  Bonders  and  Tavignot,  that  the 
weakness  of  sight  should  be  attributed  to  a  defect  of  accom- 
modation, to  paralysis  of  the  muscles  of  accommodation,  and 
perhaps  to  a  certain  degree  of  insensibility  of  the  retina  as 
well.  We  note,  however,  that  Bouchut  speaks  of  lesions  of 
the  retina  which  he  recognized  with  the  ophthalmoscope.  In 
a  recent  thesis  Perchant  took  the  same  ground.  In  certain 
cases  of  amblyopia,  not  in  all,  lesions  analogous  to  those  of 
toxic  amaurosis  will  be  met.  They  consist  of  a  neuritis  or  a 
neuro-retinitis  more  or  less  intense,  like  that  which  is  observed 
in  amaurosis  from  tobacco,  from  alcohol,  etc. 

The  muscles  of  the  eyeball  and  of  the  lids  are  not  always 
exempt.  Internal  or  external  strabismus,  of  one  or  both  eyes, 
in  the  latter  case  almost  always  convergent,  and  drooping  of 
the  upper  eyelid  are  the  result  of  paralysis  of  these  muscles. 

The  senses  of  hearings  of  taste,  of  smell  are  much  more 
rarely  affected. 

Impairment  of  the  power  of  speech  is  sometimes  quite  com- 
plete. The  speech  may  be  slow,  labored,  or  confused.  Some 
have  trouble  in  pronouncing  the  labials,  others  cannot  articu- 
late a  single  consonant.  Some  pronounce  certain  words  with 
difficulty.  They  read  quite  fluently,  but  when  they  come  to 
those  words  they  stop,  stammer,  and  sometimes  cannot  over- 
come the  obstacle.  Others  proceed  after  more  or  less  hesita- 
tion. Certain  patients  show  a  stammering  which  gives  their 
condition  a  kind  of  resemblance  to  progressive  general  paral- 
ysis. There  may  be  complete  aphonia,  as  Billard  experi- 
enced. 

The  paralysis  of  the  muscles  of  the  tongue,  of  the  pharynx, 


GENERAL    DISCRIPTION    OF    DIPHTHERIA.  169 

and  of  the  velum  palati  explains  the  impairment  of  the  power 
of  speech.  The  innervation  of  the  tongue  would  seem  to  be 
compromised,  and  we  might  be  tempted  to  refer  these  symp- 
toms to  a  lesion  of  the  medulla.  But  that  lesion  has  never 
been  found.  I  shall  have  to  fall  back  upon  the  interpretation 
which  is  wont  to  be  given  to  these  facts. 

The  intelligence  remains  intact.  If  it  sometimes  seems  al- 
tered it  is  never  wholly  abolished.  It  never  reaches  that  de- 
gree of  weakness  which  the  dull  aspect  of  the  patient  would 
seem  to  indicate,  when  he  is  seen  with  his  head  falling 
upon  his  chest,  his  tongue  lolling,  and  the  saliva  drooling 
from  his  lips.     He  understands  and  answers  to  the  point. 

General  symptoms  are  rare.  They  are  wholly  absent  in  the 
simpler  forms,  except  at  the  onset,  which  is  announced  at 
times  by  a  little  fever,  or  by  the  increase  of  albuminuria,  if 
that  exist.  But  when  paralysis  becomes  general,  we  are  often 
confronted  by  grave  symptoms,  such  as  excessive  prostration, 
or  continual  tossing,  vomiting,  convulsions,  coma  and  diar- 
rhoea, all  the  signs,  in  short,  of  ataxy  and  asthenia,  or  of  a  pro- 
found cachexia. 

The  tenniiiation  is  usually  in  recovery.  Death,  however, 
supervenes  under  many  circumstances. 

Inanition  is  one  of  the  most  frequent  causes  of  a  fatal  re- 
sult. The  difficulty  of  introducing  food,  the  fear  of  suffoca- 
tion, the  profound  disgust  inspired  by  the  rejection  of  sub- 
stances through  the  nose,  speedily  threaten  the  patient  with 
death  by  starvation  unless  the  oesophageal  tube  is  early  em- 
ployed. Yet  this  means  does  not  always  insure  the  result 
hoped  for,  and  the  patient  often  succumbs  to  the  progress  of 
cachexia. 

When  paralysis  is  generalized,  when  it  affects  the  muscles 
of  the  trunk,  causing  to  a  greater  or  less  degree  an  incom- 
plete functional  activity  of  the  lungs,  it  may  be  followed  by 
death  from  asphyxia.  Intercurrent  diseases,  such  as  simple 
attacks  of  bronchitis,  may  carry  off  the  patient  in  a  like 
manner. 

Sudden  death  is  one  of  the  accidents  to  be  feared.  It  is 
produced  in  several  ways: 


I/O  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

1,  By  paralysis  of  the  larynx,  when  a  bolus  of  food,  badly 
guided  by  the  pharynx  and  not  stopped  by  the  larynx,  both 
being  paralyzed,  enters  the  air-passages;  it  then  causes  suffo- 
catioK.  The  cases  cited  by  Gillette,  by  Tardieu  and  by  Peter 
have  shown  that  this  is  an  actual  cause  of  death. 

Paralysis  of  the  larynx,  moreover,  has  produced  death  by 
another  method.  Symptoms  such  as  aphonia,  muffled  cough 
and  sighing  respiration  denote  profound  disorder  affecting  the 
play  of  the  parts  that  form  the  larynx.  Debility  of  the  in- 
spiratory muscles  of  the  larynx  can  obtain,  as  well  as  of  the 
inspiratory  muscles  of  the  thorax  or  ol  the  neck.  If  it  remain 
partial,  respiration  can  go  on  only  imperfectly,  and  the  dis- 
turbance of  haematosis  slowly  increases  ;  but  when  it  becomes 
complete,  suffocation  is  the  immediate  result.  Gubler  has 
shown  the  possibility  of  laryngeal  paralysis.  Aubrun,  Perrin 
and  Plouviez  cite  two  cases  of  sudden  death  which  they  refer  to 
that  cause.  Two  cases  of  sudden  death  are  found  in  the  the- 
sis of  Garnier,  which  he  attributes  to  the  formation  of  heart 
clot.  They  occurred  in  children  whose  fauces  were  paralyzed, 
who  suddenly  developed  aphonia,  became  cyanotic,  and  died 
in  a  few  minutes.  As  death  at  the  heart  gives  rise  in  similar 
cases  to  syncope,  and  not  to  asphyxia,  to  pallor,  and  not  to 
cyanosis,  it  is  very  probable  that  paralysis  of  the  larynx  was 
the  real  cause  of  death,  as  the  aphonia  further  proves. 

2.  By  faralysis  of  the  heart.  I  have  shown  the  influence  of 
diphtheritic  paralysis  upon  the  heart.  I  have  described  the 
terrible  accidents  that  result  therefrom,  and  have  proved  that 
the  cardiac  disorders,  attributed  to  thrombosis,  may  be  re- 
ferred to  this  cause;  among  others,  to-wit,  sudden  death.  It 
is  in  the  midst  of  convalescence  that  these  accidents  appear. 
The  patient  falls  quickly  into  syncope  while  he  is  playing,  or 
making  some  exertion,  or  a  simple  movement,  and  dies  in  a 
moment.  In  other  cases  he  is  suddenly  seized  with  praecor- 
dial  distress  and  with  dyspnoea.  The  pulse  becomes  small, 
and  shows  a  manifest  retardation  and  irregularity  till  death 
comes  on  at  a  time  varying  from  a  few  minutes  to  a  few  hours, 
in   consequence    of  syncope   or  by  a    gradual    failure  of  the 


GENERAL    DISCRIPTION    OF    DIPHTHERIA.  I7I 

pulse.  With  a  patient  whose  pulse  had  been  examined  before 
the  onset  of  grave  complications  irregularities  were  noted  for 
several  days  before. 

In  some  very  rare  cases  diphtheritic  paralysis  may  ^,roduce 
gangrene  of  the  skin.  One  patient  with  generalized  paralysis 
presented  gangrenous  spots  upon  his  wrists  and  lower  limbs. 

The  ^^?/r.y<f  of  diphtheritic  paralysis  is  quite  uniform.  Its  lo- 
calizations are  linked  together  in  an  order  which  is  usually 
followed.  But  if  the  chain  is  regularly  formed,  the  number  of 
links  varies.  In  a  given  case  the  paralysis  may  develop  all 
its  manifestations,  or  only  present  a  number  of  them,  which  it 
is  impossible  to  determine  in  advance.  Beginning  usually  in 
the  fauces  and  the  larynx,  it  is  oftenest  arrested  in  those  parts. 
From  thence,  according  to  certain  authors,  it  will  pass  at  once 
to  the  eyes.  In  several  cases  I  have  seen  affairs  progress 
otherwise.  The  eyes  were  attacked  after  the  extremities.  It 
next  reaches  the  lower  limbs,  then  the  upper  extremities,  the 
trunk  and  the  neck.  It  invades,  finally,  the  rectum,  the  blad- 
der, and,  last  of  all,  the  organs  of  special  sense. 

Anaesthesia  almost  always  precedes  the  muscular  debility. 

Recovery  begins  at  the  lower  limbs  and  reaches  success- 
ively the  fauces,  the  upper  extremities,  the  trunk,  the  viscera 
and  the  eye.  The  organs  first  paralyzed  are  almost  always 
the  first  to  recover  their  functions. 

However  regular  the  course  of  diphtheritic  paralysis  may_ 
be,  it  offers  numerous  exceptions.  Not  a  sign  exists  that  en- 
ables us  to  see  that  any  given  organ  will  be  paralyzed.  From 
the  fact  that  the  legs  are  affected  we  cannot  conclude  that  the 
arms  will  be,  and  from  the  fact  that  the  muscles  of  the  trunk 
are  paretic  we  cannot  infer  the  relaxation  of  the  sphincters  or 
troubles  of  vision.  Moreover,  the  localizations  of  the  paral- 
ysis present,  at  times,  a  remarkable  instability,  rapid  alterna- 
tions, remissions  and  exacerbations  that  disconcert  all  prog- 
nostication. 

The  interval  that  separates  paralysis  of  the  velum  palati 
from  that  of  other  regions  may  be  very  short,  or  even  be 
wholly  wanting.     The  paralysis   may  be  general  at  the  onset. 


1/2  DIPHTHERIA,    CROUP    AND    TRACIlEOl  OMY 

or  it  may  affect  the  limbs  and  every  apparatus  while  avoiding 
the  velum  palati  and  the  pharynx,  even  where  there  has  been 
pharyngitis. 

A  small  number  of  organs  may  be  attacked  singly.  Cer- 
tain cases  have  been  seen  where  the  legs  and  the  forearms 
were  alone  affected.  In  others  it  was  the  lips,  the  sacro-lum- 
bar  muscles  and  the  lower  limbs.  In  one  patient  total  blind- 
ness was  the  only  symptom  of  paralysis.  In  some  other  cases 
the  paralysis  was  confined  to  the  muscles  of  the  trunk  and  to 
the  diaphragm  or  to  the  hands,  feet  and  to  the  sphincter  ani. 
Roger  cites  an  instance  of  paralysis  located  in  the  sphincter  ani. 

There  are  also  cases  in  which  it  affects  the  limbs  before  at- 
tacking the  pharynx  and  the  tongue.  I  have  seen  it  begin  in 
the  upper  extremities,  reach  the  velum  palati  and  the  pharynx 
and  then  attack  the  lower  limbs. 

Finally  it  has  been  observed,  in  the  absence  of  pharyngitis, 
in  diphtheria  of  the  skin,  for  example,  that  peculiarity  not  pre- 
venting the  velum  palati  being  attacked.  I  have  seen  it  in  a 
child  with  diphtheria  of  the  skin  confined  to  the  region  about 
the  umbilicus,  and  in  another  who  had  simply  diphtheria  of 
the  auricle. 

The  duration  of  diphtheritic  paralysis  cannot  be  precisely 
fixed.  Sometimes  it  is  very  brief,  A\]ien  it  is  limited  to  the 
larynx  or  the  fauces,  and  lasts  only  from  seven  to  nine  days. 
But  even  under  these  conditions  it  often  lasts  longer  and  does 
not  terminate  before  fifteen  or  eighteen  days. 

When  it  becomes  general,  or  when  it  affects  the  upper  ex- 
tremities, the  eyes,  the  face  or  the  viscera  it  is  not  rare  to  see 
it  last  for  a  period  of  from  three  to  four  months.  Exception- 
ally it  persists  from  that  to  six  or  eight  months.  Duclos  de 
Foretz,  however,  cited  by  Maingault,  reports  a  case  of  paral- 
ysis of  twenty  months  standing.  Morriseau  records  the  in- 
stance of  a  little  girl  who  was  attacked  with  diphtheritic  an- 
gina set.  8  years,  and  still  retained,  nine  years  later,  a  slight 
nasal  intonation.  One  of  the  patients  of  Roger  presented 
persistent  aphonia.  Finally,  Prosper  Faucher  has  published  a 
notice  of  a  case  of  chronic  diphtheritic  paralysis. 


GENERAL    DISCRIPTJON    OF    DIPHTHERIA.  I73 

What  is  the  rc\dit\w q  frequency  of  this  paralysis?  Every  au- 
thor who  has  tried  to  solve  this  question  has  accounted  for  the 
difficulties  which  it  presents.  Many  causes,  in  fact,  prevent 
the  ascertaining  of  paralytic  complications.  Many  patients 
die  quickly,  without  giving  the  paralysis  time  to  disappear; 
others  when  scarcely  entered  upon  convalescence  are  with- 
draw^n  from  observation  before  the  onset  of  the  paralysis.  It 
is  certain,  then,  that  statistics  give  to  the  latter  less  frequency 
.han  is  really  the  case.  They  should  not,  therefore,  be  con- 
sulted, except  with  a  view  of  approximate  estimate. 

Roger,  in  210  cases  of  diphtheria,  noted  thirty-six  cases  of 
paralysis.  From  a  table  compiled  by  Mansord  it  appears  that 
it  was  noted  by  Lemaire,  of  Pont-Audemer,  twelve  times  in 
eighteen  cases ;  by  Hermann  Weber,  sixteen  times  in  190 
cases;  by  Bouillon  Lagrange,  four  times  in  fifty;  by  Moynier, 
eight  times  in  twenty-nine ;  by  Barascut,  three  times  in  nine- 
teen; by  Sellerier,  three  times  in  160,  and  Monckton,  of  Maid- 
stone, nine  times  in  300  cases. 

In  comparing  these  statistics  we  can  see  what  an  enormous 
discrepancy  is  manifest  among  them.  Thus,  while  according 
to  Lemaire  the  proportion  is  66  per  cent,  that  is  to  say,  that 
the  majority  of  the  patients  have  exhibited  some  diphtheritic 
paralysis,  it  descends,  according  to  Monckton,  to  1.15  per 
cent.  It  seems  unlikely  that  in  this  latter  statement  some 
cases  of  paralysis  did  not  go  unrecognized.  In  1,382  cases  of 
diphtheria  I  have  met  paralysis  155  times,  which  gives  a  pro- 
portion of  II  per  cent,  or  one  in  nine,  consequently  a  little 
less  than  that  of  Roger,  which  is  one  in  six. 

There  are  enough  materials  to  allow  the  conclusion,  in  a 
general  way,  that  paralysis  frequently  accompanies  or  follows 
diphtheria. 

SequelcE. — Diphtheritic  paralysis  does  not  leave  serious  con- 
sequences behind  it.  Little  by  little  the  organs  resume  their 
motility  and  their  sensation,  whether  general  or  special. 

It  is  only  under  exceptional  circumstances  that  its  influence 
has  been  strong  enough  to  alter  the  structure  of  the  organs  it 
affected.  Kraft  Ebing  cites  a  case  in  which  a  certain  number 
of  muscles  remained  atrophied  for  a  long  time. 


1/4  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

Larue,  of  Laval,  records  his  observation  of  a  little  patient 
aet.  4  years,  who  was  attacked  subsequent  to  diphtheritic 
pharyngitis,  with  paraplegia,  without  paralysis  of  the  velum 
palati  or  of  any  other  organ.  The  extensor  muscles  of  the 
leg  and  of  the  thigh  atrophied.  The  flexors  preserved  their 
contractility,  and  brought  the  leg  into  complete  flexion  upon 
the  thigh  and  the  latter  into  extreme  flexion  upon  the  pelvis, 
so  that  the  knees  approximated  the  shoulders.  There  was  at 
the  same  time  considerable  distance  between  the  knees.  It 
was  necessary  to  employ  forced  extension  and  special  appa- 
ratus to  restore  the  limb  to  its  normal  position.  This  treat- 
ment resulted  in  cure. 

Prognosis. — Diphtheritic  paralysis  of  itself,  when  limited  to 
the  fauces  or  to  a  small  number  of  organs,  presents  but  little 
gravity.  Recovery  is  the  rule,  outside  of  very  rare  exceptions, 
which  should  be  charged  to  suffocation  by  the  entrance  of 
food  into  the  air-passages  and  to  inanition. 

On  the  contrary,  when  it  is  general,  prognosis  becomes 
more  grave.  Then,  indeed,  it  affects  the  muscles  of  respira- 
tion and  the  heart.  Death  is  brought  on  by  asphyxia  or  by 
syncope,  by  the  natural  progress  of  paralysis,  or  as  a  result  of 
a  pulmonary  complication,  often  very  slight. 

I  have,  nevertheless,  seen  a  patient  suffering  from  paralysis 
of  the  muscles  of  the  thorax  recover  in  spite  of  an  intercur- 
rent pleurisy.  In  the  absence  of  any  complication  death  re- 
sults in  severe  cases  from  defective  alimentation,  from  a  pro- 
found cachexia,  or  from  convulsions. 

Etiology. — Every  form,  every  localization  of  diphtheria,  the 
most  simple  as  well  as  the  most  grave,  the  most  extensive  as 
well  as  the  most  limited ;  whether  it  attacks  the  fauces  or  an- 
other part  of  the  body  ;  whether  albuminuria  have  been  present 
or  absent,  may  be  followed  by  paralysis.  That  point  settled,  if 
we  consider,  on  the  other  hand,  the  frequency  of  paralysis 
after  diphtheria,  we  have  a  right  to  ask  if  that  complication  is 
indeed  a  manifestation  of  diphtheria,  and  if  it  has  special 
features  that  distinguish  it  from  paralysis  following  other 
acute  diseases?  These  questions  can  be  reduced  to  one:  Is 
there  a  diphtheritic  paralysis  f 


GENERAL    DISCRIPTION    OF    DIPHTHERIA.  I75 

The  afifirmative  has  been  upheld  by  Trousseau,  by  Main- 
gault  and  by  See.  According  to  these  authors  the  paralysis 
is  due  to  the  poisoning  of  the  system  by  the  diphtheritic  virus, 
to  the  disturbance  experienced  by  the  nervous  system,  a  dis- 
turbance like  that  produced  by  poisoning  from  lead,  bisul- 
phide of  carbon,  carbonic  oxide,  and  from  certain  general  dis- 
eases, such  as  typhoid  fever,  typhus  fever,  cholera,  small-pox, 
and  other  eruptive  fevers.  Like  these  paralyses,  that  of  diph- 
theria has  some  symptoms  and  a  course  peculiar  to  itself, 
which  make  it  a  distinct  species. 

Gubler  has  undertaken  to  disprove  this  theory.  Gathering 
a  certain  number  of  observations  in  which  paralyses  had  been 
noted  as  following  simple  pharyngitis,  pneumonia,  pleurisy, 
typhoid  fever,  etc.,  some  of  which  paralyses  showed  a  more 
or  less  marked  resemblance  to  that  of  diphtheria,  he  concludes 
therefrom  that  there  is  not  a  special  diphtheritic  paralysis,  and 
that  the  disturbances  of  motility  and  of  sensibility  which  fol- 
low diphtheria  should  be  classed  with  those  that  follow  acute 
diseases  in  general,  and  that  they  arise  from  debility  of  the  or- 
ganism, or,  to  use  Gubler's  expression,  asthenia,  resulting  from 
the  intensity  of  the  fever,  from  prolonged  low  diet,  from  loss 
of  blood,  from  albuminuria,  and  from  all  other  causes  of  or- 
ganic decline.  Moreover,  according  to  the  same  author,  the 
importance  of  diphtheria  has  been  over-estimated  to  the  neg- 
lect of  simple  pharyngitis,  by  attributing  to  the  former  paral- 
ysis resulting  from  herpetic  pharyngitis. 

The  learned  professor  has  rendered  service  to  science  by 
drawing  attention  to  a  class  of  paralyses  but  little  studied. 
Paralysis  of  the  velum  palati,  resulting  from  simple  pharyn- 
gitis, seems  well  established,  but  it  is  less  common  than  one 
would  think,  a  priori.  In  fact,  the  herpetic  pharyngitis, 
which  Gubler  classes  among  the  forms  of  simple  pharyngitis, 
is  but  too  often,  as  I  shall  show  later,  a  form  of  diphtheria. 
Moreover,  we  must  further  discriminate  between  cases  of 
pharyngitis  without  exudation.  Without  wishing  to  give  too 
much  importance  to  the  slightly  paradoxical  expression: 
Diphtheria  without  diphtheria  {diphtherie  sans  diphtherie),  it  is 


1/6  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

incontestable  that  in  times  of  epidemic  we  meet,  side  by  side, 
and  in  the  same  surroundings,  with  severe  and  well  marked 
cases,  other  very  benign  cases  which,  as  they  were  engen- 
dered by  the  former,  or  transmit  by  contagion  (a  severe 
form  of  the  disease),  evidently  come  from  the  same  source.  In 
these  cases  the  local  symptoms  are  light,  almost  impercepti- 
ble, and  are  reduced  to  a  simple  redness;  the  false  membrane 
is  slight  or  absent ;  the  disease  is  defaced  [friiste),  to  use 
Trousseau's  expression,  and  behaves  as  scarlatina,  typhoid  fe- 
ver, yellow  fever,  etc.,  often  do.  But  just  as  in  those  forms  of 
scarlatina  that  appear  so  light  we  may  all  at  once  see  compli- 
cations like  albuminuria  and  anasarca  become  prominent, 
revealing  the  true  character  of  the  disease ;  so  diphtheria, 
though  scarcely  discernible  in  the  fauces,  may  make  itself 
known  by  secondary  symptoms,  such  as  albuminuria  and 
paralysis. 

Paralysis  following  herpetic  pharyngitis  and  pharyngitis 
without  false  membrane  should  not,  therefore,  be  taken  as  ir- 
refutable proof  of  the  existence  of  paralysis  unconnected  with 
diphtheria.  It  is  very  probable  that  many  of  these  cases  are 
in  fact  due  to  diphtheria.  * 

This  does  not  mean  that  simple  pharyngitis,  resulting  from 
a  cold,  in  the  absence  of  any  epidemic,  without  any  source  of 
contagion,  may  not  bring  in  its  train  a  paralysis  of  the  velum 
palati  and  of  the  pharynx.  The  fact  has  been  confirmed  by 
credible  observers.  It  should  be  admitted.  But  still  it  is  the 
exception  while  paralysis  following  diphtheria  is  frequently 
observed. 

The  importance  of  this  discovery  would  be  insignificant  if 
we  had  only  to  point  out  paralysis  of  the  fauces  as  following 
simple  pharyngitis.  The  violence  of  the  inflammation,  its 
propagation  in  the  submucous  muscular  layers  would  explain 
it,  as  Zenker,  Hayem  and  others  have  shown,  but  in  very  rare 
cases  these  nervous  troubles  have  been  seen  to  extend,  to  at- 
tack several  apparatus,  and  to  take  on  a  certaia  resemblance 
to  diphtheritic  paralysis.  Some  other  morbid  states,  as  typhoid 
fever,  small-pox,  erysipelas,  pleurisy,  etc.,  have,  exceptionally, 


GENERAL    DISCRIPTION    OF    DIPHTHERIA.  177 

it  is  true,  given  rise  to  analogous  observations.  The  circum- 
stances under  which  these  paralyses  are  presented  justify  the 
asthenic  origin  to  which  Gubler  refers  them.  They  are  al- 
most always  met  after  very  severe  and  very  protracted  illness, 
during  which  the  patient  has  been  subjected  to  a  restricted 
diet  and  to  a  reducing  treatment.  Those  of  diphtheria  are 
developed,  on  the  contrary,  in  entirely  different  connections. 
Far  from  choosing  severe  and  protracted  cases,  it  often  fixes 
upon  benign  cases,  in  which  the  fever  has  been  slight  and 
brief,  and  following  which  the  patients  do  not  seem  at  all 
cachectic.  Moreover,  by  reason  of  the  character  of  the  diph- 
theria, undoubtedly  obscure  at  times,  we  may  ask  if  its  inter- 
vention has  not  been  mistaken  in  many  instances. 

Even  admitting  that,  besides  diphtheria,  certain  acute  dis- 
eases may  leave  behind  them  acute  paralytic  troubles  that  con- 
form quite  closely  to  the  type  of  post-diphtheritic  paralysis, 
we  must  agree  that  compared  with  the  former,  the  latter  pre- 
sent a  crushing  numerical  superiority. 

From  this  frequency,  from  this  very  peculiar  stamp  which 
paralysis  following  diphtheria  always  preserves,  from  this  great 
difference  in  the  conditions  that  preside  at  the  onset  of  these 
paralyses  according  as  they  belong  to  diphtheria  or  to  other 
acute  diseases,  we  can  conclude  that  diphtheritic  infection  has 
an  action  on  the  nervous  system  which  is  probably  special, 
which,  in  any  event,  is  infinitely  greater  than  that  of  any  other 
acute  disease,  and  that  the  paralytic  complications  which  it  de- 
termines deserve  to  be  grouped  under  the  name  of  diphtheritic 
paralysis. 

Pathogenesis. — Many  theories  have  been  proposed  to  explain 
the  mode  of  the  production  of  diphtheritic  paralysis.  Let  us 
first  examine  what  has  been  said  in  explanation  of  the  paral- 
ysis of  the  palate.  The  first  thought  of  observers  has  been 
to  connect  it  with  inflammation  of  the  mucous  membrane ; 
that  propagation  of  the  process  to  the  muscular  layers,  and  to 
the  subjacent  nerve  termini,  abolished  the  functions  of  these 
organs.  The  works  of  Zenker,  Hayem,  Liouville,  Charcot  and 
Vulpian,  and   Lorain  and   Lepine   have,  to  a  certain   degree, 


178  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

given  sanction  to  this  hypothesis.  These  authors  have  proved 
the  alteration  of  the  nerve  termini  in  certain  cases  of  paralysis 
of  the  palate.  But,  while  according  a  certain  role  to  the  in- 
flammation, we  must  be  careful  not  to  make  it  too  important ; 
this  reserve  would  be  needless  did  paralysis  always  follow  diph- 
theritic pharyngitis  having  a  violent  inflammatory  course.  But 
such  is  not  at  all  the  case.  Not  only  is  this  kind  of  pharyn- 
gitis not  always  followed  by  paralysis,  but  the  latter  is  ob- 
served after  pharyngitis  of  very  slight  intensity.  Moreover,  it 
has  been  noted  in  cases  wh^re  pharyngitis  did  not  exist,  where 
the  diphtheria  occupied  no  locality  but  the  skin.  Besides,  it 
the  inflammatory  element  had  any  real  importance,  paralysis 
should  often  follow  simple  pharyngitis,  in  which  the  inflamma- 
tory condition  is  often  very  intense,  much  more  so  than  in 
diphtheritic  pharyngitis.  But  how  rarely  is  paralysis  produced 
under  these  circumstances  compared  with  that  which  follows 
diphtheria.  We  must  admit,  then,  that  diphtheria  has  a  spe- 
cial power  to  engender  paralysis.  How  is  this  power  exercised  ? 
As  far  as  concerns  the  paresis  of  the  palate  after  pharyngitis, 
the  interpretation  is  easily  presented.  The  lesions  of  the  ends 
of  the  palatine  nerves  described  by  Charcot  and  Vulpian, 
found  also  by  Lorain  and  Lepine  and  several  German  authors, 
give  the  key  to  these  phenomena.  I  have  described  these  les- 
ions in  the  pathological  anatomy  and  I  will  return  to  them 
later.  The  paralysis  of  the  velum  palati  seems  to  be  pro- 
duced by  a  peripheral  alteration  of  the  palatine  nerves,  an  al- 
teration which  results  from  the  action  of  diphtheritic  virus 
upon  the  nervous  system. 

The  generalization  of  the  paralysis  is  more  difficult  to  ex- 
plain. The  theories,  moreover,  are  more  numerous.  Gubler 
divides  these  paralytic  difficulties  into  two  classes,  holding  that 
some  are  due  to  the  propagation  ot  lesions  that  exist  in  the 
pharynx  along  other  nerves;  and  that  the  others  are  of  asthenic 
character.  The  first  class  are  those  of  sight,  of  taste,  of  hear- 
ing, paralysis  of  the  tongue,  the  lips,  the  face,  the  muscles  of 
the  neck,  respiratory  and  cardiac  disorders.  The  proximity 
of  the  superior  cervical  ganglion  permits  the  visual  troubles  to 


GENERAL    DISCRIPTION"    OF    DIPHTHERIA.  1 79 

be  attributed  to  the  great  sympathetic.  The  anastomoses  of 
the  great  sympathetic  with  the  facial  and  the  trigeminal, 
Meckel's  ganglion,  the  origin  of  the  palatine  nerves,  would  ex- 
plain the  weakening  of  taste  and  hearing,  and  the  paralysis  of 
the  lips  and  face.  Moreover,  we  find  beside  the  pharynx,  the 
trunks  of  the  glosso-pharyngeals,  of  the  pneumogastric  and 
of  the  great  sympathetic,  the  roots  of  the  cervical  plexus,  the 
pharyngeal  plexus  into  which  enter  branches  from  the  pneumo- 
gastric, the  glosso-pharyngeal  and  the  great  sympathetic. 
The  propagation  of  the  pharyngeal  inflammation  to  these  very 
important  organs  would  explain  the  paralysis  of  the  neck,  the 
insensibility  of  the  tongue,  the  cardiac  and  pulmonary  troub- 
les. Nothing  could  be  more  ingenious  than  this  physiological 
mechanism.  It  would  be  all  very  well  if  the  pharyngitis  or 
the  pharyngeal  paralysis  were  a  condition  necessary  to  the 
paralysis  of  other  organs.  But  we  know  that  the  latter  may 
exist  without  having  been  preceded  by  either  pharyngitis  or 
paralysis  of  the  palate ;  still  more,  paralysis  of  the  palate 
sometimes  follows  a  diphtheria  which  has  not  touched  the 
fauces.  And  further,  we  should  still  ask  why  these  re- 
flexions along  neighboring  nerves  are  so  rare  in  simple 
inflammatory  pharyngitis  even  when  very  intense,  and  why 
they  should  be  so  common  in  diphtheria  even  after  such 
forms  as  are  locally  the  least  marked,  while  we  have  seen  them 
absent  after  the  most  violent  pharyngeal  manifestations.  We 
must  then  admit,  here  also,  that  diphtheria  has  a  special  action 
on  these  paralyses. 

Does  the  doctrine  of  asthenia  explain  the  mechanism  of 
the  remote  paralyses  any  better?  I  think  not.  Often  the 
pharyngitis  which  preceded  has  been  very  mild,  there  has  been 
little  fever,  the  thermic  curve  has  shown  but  an  insignificant 
rise,  the  patient  is  well  nourished,  he  has  been  under  a  tonic 
regimen,  and  nothing  about  him  points  to  asthenia,  that  is  to 
say,  a  general  exhaustion  due  to  denutrition  of  the  tissues. 
Hermann  Weber  makes  the  same  remark.  He  shows  that 
English  physicians  employ  largely  in  the  treatment  of  diph- 
theria, wine,  tonics  and  alimentation,   which  does   not  prevent 


l8o  niPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

their  having  their  full  quota  of  secondary  paralyses  even  after 
evidently  mild  cases. 

I  do  not  pretend  that  asthenia  is  of  no  effect  in  any  case. 
Its  action  is  too  evident  in  many  cases  of  diphtheria  for  one  to 
think  of  denying  it,  but  it  should  be  considered  solely  as  a 
secondary  cause. 

Would  a  lesion  of  the  nerve  centres,  of  the  medulla  ob- 
longata in  particular,  explain  it  better?  The  medulla,  presid- 
ing as  it  does,  over  deglutition,  facial  expression,  mastication, 
speech,  cardiac  and  respiratory  movements,  has  been  scrupu- 
lously examined  as  to  its  condition.  It  has  never  been  found 
altered  more  than  other  portions  of  the  nerve  centres.  More- 
over, it  would  be  hard  to  reconcile  the  existence  of  a  lesion 
of  the  cerebrum  or  medulla  with  the  changeability  of  symp- 
toms which  often  characterizes  diphtheritic  paralysis. 

Several  authors,  among  others  Brown-Sequard,  See  and 
Colin,  have  sought  to  class  these  paralytic  phenomena  in  the 
category  of  reflex  paralyses. 

In  support  of  this  hypothesis,  Colin  lays  hold  of  a  fact  al- 
ready cited  by  Blache,  relating  to  a  child  that  pricked  itself 
in  the  soft  palate  with  a  crochet  needle.  A  local  paralysis 
supervened,  followed  by  general  paralysis,  resembling  diph- 
theritic paralysis.  Reflex  action  is  evident  in  this  case,  but 
what  correspondence  can  be  found  between  this  and  a  diph- 
theritic pharyngitis  and  its  subsequent  paralysis  ?  None,  what- 
ever. If  paralysis  should  supervene  during  the  course  of  an 
inflammation  of  the  fauces  I  would  have  no  hesitation  in  re- 
garding it  as  reflex.  But  at  what  period  do  we  see  the  paral- 
ysis of  diphtheria  appearing?  During  convalescence,  from 
eight  to  fifteen,  and  even  thirty  days  after  recovery.  How,  in 
such  a  case,  can  a  relation  be  established  between  the  pharyn- 
gitis and  the  paralysis?  Furthermore,  the  reflex  theory  is 
untenable,  except  in  case  of  pharyngitis.  Colin,  indeed,  con- 
siders the  paralysis  of  the  palate  as  a  necessary  intermediate 
between  the  pharyngitis  and  the  generalization  of  the  amyo- 
sthenia.  But  that  "  necessary  intermediate  "  is  wanting  in  a 
certain  number  of  cases  of  pharyngitis  followed  by  general 
paralysis. 


GENERAL    DISCRIPTION    OF    DIPHTHERIA.  l8l 

Hermann  Weber  has  given  out  an  ingenious  variation  of  the 
reflex  theory.  Likening  that  which  goes  on  in  diphtheria  to 
what  is  observed  in  traumatic  tetanus,  he  reminds  us  that  in 
the  latter  disease  functional  troubles  can  be  produced  in  the 
nerve  centres,  consequent  upon  peripheral  lesions,  even  after 
recovery  from  those  lesions.  It  would  be  possible  for  diph- 
theria to  show  a  like  peculiarity,  "  Diphtheria  and  traumatic 
tetanus  have  this  in  common  :  i.  Between  the  peripheral  le- 
sion or  modification  and  the  onset  of  the  central  disturbance 
there  elapses  a  variable  period  of  time.  2.  As  wounds  do  not 
result  in  tetanus  except  in  rare  cases,  so  the  difficulties  in 
question  follow  only  certain  cases  of  diphtheria ;  and  finally, 
3.  Just  as  the  smallest  wounds  may  produce  tetanus,  so  the 
mildest  cases  of  diphtheria  may  cause  subsequent  nervous 
difficulties." 

This  explanation,  which  the  author  gives,  moreover,  with  all 
caution,  explains  no  better  than  the  former  ones,  those  cases 
of  paralysis  unpreceded  by  pharyngitis. 

Neither  should  albuminuria  be  assigned  as  the  cause. 
Trousseau  has  taken  pains  to  show  that  the  difficulties  of  sight 
following  diphtheria  were  not  dependent  upon  albuminuria. 
Diphtheritic  paralysis  is  not  met  with  in  patients  only  that 
have,  or  have  had  albuminuria.  Further,  there  is  nothing 
in  common,  as  the  ophthalmoscope  has  shown,  between  the 
diphtheritic  and  albuminuric  defects  of  vision. 

The  preceding  critical  examination  leads  to  the  conc'usion 
that  diphtheritic  paralysis  should  be  attributed  neither  to  the 
excess  of  inflammation  in  the  diseased  part  nor  to  its  re- 
flection along  the  nerves  of  neighboring  regions ;  and  that  it 
is  accounted  for  neither  by  asthenia,  nor  by  a  central  lesion, 
nor  by  reflex  action. 

If  it  be  not  referable  to  any  of  these  causes,  nothing  further 
remains  but  to  regard  it  as  a  peripheral  paralysis.  This  view- 
can  be  supported  by  several  proofs.     They  are  : 

1.  The  course  of  the  paralysis  which  always  begins  at  the 
periphery. 

2.  The  results  of  examination  by  electricity.     The  muscular 


1 82  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

contractility  is  notably  increased  under  the  influence  of  gal- 
vanism, while  it  is  abolished  or  considerably  diminished  when 
it  is  examined  with  the  induced  current.  But  this  is  one  of 
the  most  valuable  signs — we  might  say  the  most  certain — for 
recognizing  the  peripheral  origin  of  a  paralysis.  Kraft  Ebing, 
Rosenthal,  Erb,  Duchenne,  Legros  and  Onimus,  have  suffi- 
ciently insisted  on  this  point. 

3.  The  lesions  of  the  periphery  of  the  nervous  system. 
While,  indeed,  observers  have  found  no  appreciable  lesions  in 
the  centres,  they  have  met  in  the  nerve  endings  alterations 
which  I  have  described.     We  will  recall  them  in  a  few  words. 

In  the  observation  published  by  Charcot  and  Vulpian  the 
palatine  nerves  were  altered,  certain  nerve  tubules  being  with- 
out myeline,  and  granular  bodies  were  seen  beneath  the  neuri- 
lemma. A  small  number  of  nerve  filaments  were  wholly  de- 
generated, and  the  rest  partially.  The  latter  were  composed 
of  two  kinds  of  filaments ;  the  medullary  substance  was 
healthy  in  some,  in  others  granular  and  presenting  besides 
minute  fatty  granulations  disseminated  either  among  the 
tubes  or  within  the  common  neurilemma.  Lorain  and  Lepine 
observed  a  like  case. 

Biihl  has  described  a  nucleolar  infiltration  which  he  found 
not  only  in  the  false  membrane  and  in  the  subjacent  mucous 
membrane,  but  also  in  the  healthy  mucous  membranes,  and  in 
the  roots  and  sheaths  of  the  nerves;  whence  the  paralysis. 

Oertel(see  Path.  Anat.,  p.  126)  has  many  times  met  capillary 
haemorrhages  in  the  sheaths  of  the  nerve  roots  and  in  the 
peripheral  nerves. 

H.  Liouville,  cited  by  Bailly,  (see  Path.  Anat.,  p.  127)  found 
the  phrenic  nerves  affected. 

Lyden  also  reports  a  case  (see  Path.  Anat.,  p.  126). 

We  may  then  consider  the  existence  of  these  lesions  of  the 
peripheric  nerves  as  an  assured  fact,  The  preceding  examples 
establish  it  in  due  form.  Although  few  in  number  they  are 
none  the  less  of  great  value.  Their  rarity  is  easily  explained. 
For  a  long  time  investigations  have  been  guided  solely  in  the 
direction  of  the  nerve  centres.     It  is  only  after  repeated  fail- 


GENERAL    DISCRIPTION    OF    DIPHTHERIA.  I83 

ures  in  this  line  that  they  have  been  directed  to  the  peripheral 
nerves. 

We  can  deduce  from  the  existence  of  these  lesions,  together 
with  the  absence  of  central  changes,  that  diphtheritic  paral- 
ysis is  produced  by  the  action  of  the  diphtheritic  poison  upon 
the  nerve  endings.  Like  curare,  its  toxic  principle  would 
seem  to  have  an  affinity  for  that  part  of  the  nervous  system. 
From  its  action  there  would  seem  to  result  a  neuritis  of  the 
peripheral  endings,  oftenest  affecting  the  fauces  and  the  larynx 
exclusively  or  at  the  first,  but  capable  of  beginning  in  any 
other  region  and  of  invading  successively,  and  sometimes  al- 
most simultaneously,  very  extensive  surfaces,  commencing  al- 
ways in  the  peripheral  expansions.  This  neuritis  may  fail  to 
appear,  like  the  pulmonary  complications,  the  albuminuria  or 
the  hsemorrhages,  as  diphtheria  does  not  always  present  itself 
with  the  complete  array  of  its  symptoms. 

CHANGES    IN    THE    URINE. 

Beside  the  albuminuria  whose  frequency  would  merit  a  sep- 
arate place,  there  should  figure  certain  variations  in  the  quan- 
tity of  the  urine,  as  well  as  in  the  proportions  of  its  constitu- 
ent elements. 

The  urine  is  often  lemon  colored  and  transparent,  but  we 
also  find  it  darker,  the  color  of  broth,  and  leaving  on  cooling 
an  abundant  deposit  of  urates. 

The  oscillations  that  occur  in  its  quantity  and  in  its  compo- 
sition in  certain  cases,  have  been  studied  by  Callandreau  Du- 
fresse.     I  give  a  resume  of  his  researches. 

The  quantity  of  the  urine  diminishes  in  proportion  to  the  in- 
tensity of  the  fever;  when  the  latter  diminishes,  the  quantity 
of  the  urine  again  increases.  During  convalescence  the  ex- 
cretion is  abundant,  but  when  the  case  is  about  to  end  fatall}'-, 
it  is  considerably  reduced. 

The  density  is  increased  during  the  early  days ;  it  is  repre- 
sented by  1016,  1018,  1022.  It  augments  during  the  suffoca- 
tive period  of  croup,  when  it  is  1028.  Following  an  operation 
it  diminishes  for  a  short  period,  stops  at  from  1009  to  1012; 
but  soon  rises  to  1017,  1025  or  higher. 


184  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

In  case  of  recovery  it  remains  between  1026  and  1028,  then 
falls  to  the  normal.  During  the  first  days  of  convalescence  it 
undergoes  a  slight  increase,  1015  to  1020. 

In  case  of  death  it  continues  to  rise,  reaching  1034  or  1038, 
but  generally  oscillates  about  1033. 

The  curve  of  density  has,  therefore,  a  course  parallel  with 
that  of  temperature,  and  in  the  latter  part  of  the  disease  it 
rises  and  falls  at  the  same  time. 

Urea. — The  quantity  of  this  substance  has  been  determined 
only  in  cases  of  croup  and  after  operation.  Many  changes 
may  present  themselves. 

If  the  diuresis  mentioned  above  comes  on  after  the  opera- 
tion, the  urea  increases  at  the  same  time  to  15  or  18  grams, 
quite  a  considerable  amount  compared  with  the  averag^e  for 
that  age,  which  is  about  10  grams.  Then  comes  a  relative 
diminution,  14  to  16  grams,  during  the   duration  of  this   fever. 

If  the  end  is  to  be  fatal  the  diminution  continues  and  the 
urea  falls  to  4,  to  3,  to  I  gram.  It  diminishes  while  the  den- 
sity augments. 

In  some  other  cases  the  urea  behaves  otherwise.  There  is 
no  increase  after  the  operation;  it  remains  at  from  9  to  12 
grams,  then  increases  during  the  subsequent  days  up  to  12 
and  15  grams. 

If  the  patient  recover  it  diminishes  with  the  temperature, 
save  a  slight  increase  during  the  first  days  of  convalescence. 
If  the  issue  is  to  be  fatal  the  urea,  after  a  slight  increase,  di- 
minishes, as  in  the  preceding  case,  while  the  quantity  of  the 
urine  is  diminishing  and  its  density  rising. 

Chlorme. — Callandreau  Dufresse  measured  also  the  quantity 
of  chlorine  excreted  in  the  urine.  A  simple  calculation, 
based  upon  equivalents,  enables  us  to  obtain  the  sum  total  of 
the  chlorides. 

When  there  is  a  slight  polyuria  after  the  operation,  there  is 
augmentation  of  the  chlorine  ;   3,  4  and  5  grams  are  found. 

If  the  termination  is  to  be  favorable,  there  is  a  slight  eleva- 
tion likewise  during  convalescence,  then  a  return  to  the  nor- 
mal. Is  not  this  augmentation,  coincident  with  convales- 
cence, explained  by  the  change  in  diet? 


GENERAL    DISCRIPTION    OF    DIPHTHERIA.  185 

If  death  be  near,  the  chlorine  diminishes  like  the  urea.  It 
may  fall  to  0.30  grams  although  the  child  is  eating  and  drink- 
ing a  good  deal.  These  results  should  not  be  accepted  with- 
out reserve,  as  the  mode  of  alimentation  may  exert  a  power- 
ful influence  on  the  amount  of  chlorine  excreted. 

Sugar. — The  analyses  made  by  Fouris  to  determine  the 
presence  of  sugar  have  given  only  negative  results 

SECONDARY    DIPHTHERIA. 

All  that  has  been  so  far  said  of  diphtheria  presupposes  that 
the  disease  has  attacked  a  person  in  health.  At  the  begin- 
ning of  the  chapter  on  diphtheria  in  general  I  observed  that 
this  disease,  when  secondary,  takes  on  no  new  features.  It  is 
distinguished  from  primary  diphtheria  only  by  its  persistence 
in  assuming  infectious  or  malignant  forms  and  by  its  well 
marked  tendency  toward  localization  in  those  organs  which 
are  pre-eminently  the  seat  of  the  primary  disease. 

It  will  be  seen  on  consulting  the  etiology  that  diphtheria  is 
encountered  during  the  course  of  or  following  numerous  dis- 
eases. Some  of  them  seem  to  have  a  special  fecundity  in  giv- 
ing rise  to  diphtheria.  These,  likewise,  are  specific  diseases  : 
measles,  scarlatina,  whooping  cough.  Others  predispose  to 
diphtheria  only  by  the  deterioration  they  inflict  upon  the 
economy  and  by  the  long  sojourn  they  necessitate  in  sur- 
roundings where  the  patient  is  exposed  to  contagion.  All 
cachexias  and  all  protracted  diseases  are  of  this  class. 

Diphtheria  following  specific  diseases  attacks  the  same  lo- 
calities as  they. 

That  which  follows  measles  almost  always  attacks  the  air- 
passages.  In  ninety-three  cases  twenty  were  of  the  larynx 
alone,  and  nineteen  of  the  larynx  and  fauces  together.  In 
these  nineteen  cases  the  pharyngitis  appeared  a  goodly  num 
ber  of  times,  after  croup,  evidently  the  croup  extending  up- 
wards. In  the  same  ninety-three  cases  four  others  were  of  the 
fauces,  the  larynx  and  the  nasal  fossae,  seven  were  of  the  lar- 
ynx and  bronchi,  three  of  the  fauces,  the  larynx  and  the  bron- 
chi.    Thirty-four  others  affected  the  larynx   in  company  with 


l86  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

other  organs,  such  as  the  nasal  fossae,  the  tongue,  the  gums, 
the  eyelids,  the  genitals.  In  one  case  only  was  the  diphtheria 
limited  to  the  nasal  fossae.  In  summing  up  these  different 
types  we  see  that  in  eighty-eight  cases  out  of  the  ninety-three 
the  air-passages  were  the  site  of  the  false  membrane.  This  local 
disposition  is  in  close  relation  to  that  which  measles  prefers, 
whose  affinity  for  the  same  regions  is  well  known.  In  those 
that  remain,  the  fauces  alone,  the  skin,  the  lips,  the  tongue, 
and  the  eyelids,  have  been  the  site  of  the  exudate.  It  is  proper 
also  to  notice  that  in  all  these  cases  the  local  manifestations 
were  more  or  less  numerous;  measles,  of  all  diseases,  being 
the  one  that  gives  rise  to  generalization  of  diphtheria. 

Following  scarlatina  the  aspect  is  entirely  different,  just  as 
this  exanthem  voluntarily  respects  mucous  membranes  with 
the  exception  of  the  fauces,  the  diphtheria  which  follows  scar- 
latina chiefly  threatens  the  fauces,  and  if,  in  certain  cases,  we 
encounter  it  in  other  places,  in  the  nasal  fossae  and  in  the 
larynx  we  may  be  almost  sure  that  the  fauces  have  been 
its  starting  point.  It  is  in  exceptional  cases  that  the  fauces 
are,  or  seem  to  be  intact.  In  thirty-nine  cases  of  scarlatinous 
diphtheria  the  fauces  remained  well  only  three  times ;  they 
were  attacked  alone  fifteen  times;  together  with  the  larynx, 
four  times;  with  the  nasal  fossae,  eight  times;  with  the  larynx 
and  nasal  fossae  together,  four  times ;  with  the  larynx  and  the 
bronchi,  once ;  with  the  nasal  fossae  and  the  lips,  once ;  with 
the  lips  and  the  skin,  once.  In  two  cares  the  diphtheria  was 
general ;  in  two  others  the  larynx  was  alone  affected,  and  in 
one  other  membranous  coryza  was  the  sole  local  manifestation 
of  the  diphtheria. 

Whooping  cough,  whose  action  is  normally  felt  particularly 
in  the  respiratory  mucous  membrane,  gives  rise  to  a  diphtheria 
which,  like  that  of  measles,  bears  principally  upon  the  same 
regions.  In  eighteen  cases  of  diphtheria  following  whooping 
cough,  the  respiratory  tract  was  the  seat  of  the  false  mem- 
brane fourteen  times.  Of  that  number  the  larynx  alone  was 
attacked  five  times;  together  with  the  fauces,  five  times;  with 
the  skin,  once ;  with  the  fauces  and  the  lips,  once.     In  one 


GENERAL    DISCRIPTION    OF    DIPHTHERIA.  1 8/ 

case  the  bronchi  were  invaded  at  the  same  time  with  the  nasal 
fossae  and  the  mouth,  and  lastly,  in  another,  the  nasal  fossae 
were  affected  at  the  same  time  with  the  fauces.  I  find  but 
four  cases  in  which  the  air-passages  escaped ;  the  parts  cov- 
ered by  the  diphtheria  being  the  fauces  alone  in  two  cases ; 
the  fauces  and  the  Hps  in  one  case,  and  the  skin  and  the  lips 
in  the  last. 

As  to  diphtheria  which  supervenes  as  a  last  phenomenon  in 
protracted  diseases,  chronic  or  cachectic,  it  shows  a  well- 
marked  tendency  toward  generalization.  It  almost  always  at- 
tacks simultaneously  the  larynx,  the  bronchi,  the  nasal  fossae 
and  the  pharynx ;  often  the  skin,  the  lips,  the  tongue  and  the 
conjunctiva,  together  or  separately. 

Prognosis. — What  I  have  just  shown  on  the  subject  of  the 
localization  of  secondary  diphtheria,  and  above  all,  of  its  ten- 
dency toward  generalization,  will  serve  to  show  the  gravity  of 
the  prognosis.  In  247  cases  the  issue  was  fatal  in  196;  recov- 
ery was  obtained  in  forty-three ;  the  result  was  doubtful  in 
eight  cases,  which  gives  about  one  recovery  in  five  cases. 

But  the  principal  interest  consists  in  finding  out  the  influ- 
ence of  each  particular  disease  upon  the  mortality. 

Measles  gave,  in  100  cases,  eighty-three  deaths,  fifteen  re- 
coveries and  two  doubtful  cases,  i.  e.,  one  recovery  in  about 
seven  cases. 

Scarlatina  gave,  in  forty-three  cases,  twenty-two  deaths,  sev- 
enteen recoveries  and  four  doubtful  cases;  i.  e.,  one  recovery 
in  two  and  a  half  cases. 

Whooping  cough  gave,  in  twenty  cases,  twelve  deaths,  six 
recoveries,  and  two  doubtful  cases,  i.  e.,  one  recovery  in  three 
cases. 

Typhoid  fever  gave,  in  eight  cases,  eight  deaths. 

Tuberculosis  gave,  in  nineteen  cases,  nineteen  deaths. 

Four  cases  of  diphtheria,  coming  on  in  patients  sick  with 
pneumonia,  all  ended  in  death,  as  also  four  others  which  came 
on  after  pleurisy. 

Two  cases  following  small-pox,  two  after  urticaria,  one  after 
cholera,  and  one  after  purulent  ophthalmia,  were  all  fatal.    The 


l88  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

various  cachexias,  such  as  scrofula,  rachitis,  chronic  diarrhoea, 
in  thirty-five  cases  gave  thirty-two  deaths  and  three  recover- 
ies, i.  e.,  one  recovery  in  about  twelve  cases. 

In  the  scale  of  gravity  there  come  then  in  the  first  rank 
cases  of  diphtheria  engrafted  upon  tuberculosis  and  upon  ty- 
phoid fever;  all  ended  in  death. 

Those  following  pleurisy,  pneumonia,  small-pox,  urticaria, 
have  given  the  same  result,  but  they  are  too  few  in  number  to 
warrant  rigorous  conclusions.  Then  come  diphtherias  devel- 
oped in  cachectic  patients. 

In  the  third  rank  comes  measles;  in  the  fourth,  scarlatina, 
and  in  the  fifth,  whooping  cough. 

The  course  of  secondary  diphtheria  is  usually  rapid.  Its 
duration  is  most  commonly  short,  especially  when  the  disease 
ends  in  death;  in  the  contrary  event  the  disease  lasts  much 
longer.  One  or  two  days  often  suffice  to  bring  death.  Ty- 
phoid fever  and  tuberculosis  are  distinguished  by  the  rapidity 
which  they  impress  upon  the  course  of  diphtheria. 

In  eight  cases  of  diphtheria  following  typhoid  fever  two 
cases  ended  in  one  day,  three  in  two  days,  the  three  others 
did  not  last  beyond  the  fifth  day. 

In  eighteen  cases  following  tuberculosis  three  died  in  one 
day  and  six  in  two  days. 

The  maximum  of  deaths  in  diphtherias  following  cachexias 
occurs  the  second  day.  In  those  that  belong  to  measles,  as  is 
shown,  upon  the  second  and  third  days  equally. 

Scarlatina  does  not  exercise  a  manifest  influence  upon  the 
course  of  diphtheria.  The  most  common  duration  is  ten  days. 
Three  cases  only  ended  in  two  days. 

From  the  numbers  which  precede  we  may  conclude  that 
secondary  diphtheria  has  a  very  great  tendency  to  become 
general,  that  its  prognosis  is  very  grave,  and  that  it  is  very 
rapidly  fatal.  Some  reservations  may  be  made  in  favor  of  the 
diphtheria  of  scarlatina  and  that  of  whooping  cough. 


ARTICLE  SECOND— ON  THE  LOCALIZATIONS  OF 
DIPHTHERIA. 


All  mucous  membranes,  especially  those  that  are  in  contact 
with  the  external  air,  and  even  the  skin,  serve  as  a  substratum 
for  the  false  membrane.  From  the  junction  of  the  symptoms 
of  the  diphtheritic  infection  with  the  functional  troubles  which 
arise  from  the  presence  of  the  false  membrane,  there  arise  as 
many  different  symptomatic  groups  as  there  are  localizations. 
We  shall  have  to  study  successively  the  following  morbid  con- 
ditions: 

Diphtheritic  pharyngitis,  croup,  pseudo-membranous  bron- 
chitis, diphtheritic  coryza,  oculo-palpebral  diphtheria,  diphthe- 
ritic otitis,  buccal  diphtheria,  diphtheria  of  the  anus  and  of 
the  genitals,  and  cutaneous  diphtheria. 

§  I.     Diphtheritic  Pharyngitis.  (Angina.) 

This  is  the  idctis  Syriacmn  or  Egypticmn  of  the  ancients,  the 
ajtgina  maligna  or  angina  gangrenosa  of  the  authors  of  the 
middle  ages  and  of  later  times. 

The  three  forms  of  diphtheria  which  I  have  recognized  will 
guide  me  in  the  description  of  diphtheritic  pharyngitis.  I 
shall  consider  successively  the  three  principal  types  in  which 
it  usually  appears,  viz.,  benign  pharyngitis,  infections  pharyn- 
gitis and  malignant  pharyngitis.  It  would  be  rash  to  pretend 
that  all  cases  of  diphtheritic  pharyngitis  are  ranged  exactly 
within  these  three  groups;  degrees  must  be  established  within 
these  forms  as  intermediate  cases  may  be  found.  It  is  just  so 
in  all  clinical  classifications ;  they  should  not  claim  an  abso- 
lute exactness,  but  they  should  aim,  while  giving  as  close  an 
approximation  as  possible,  at  clearness  of  exposition,  and  they 
attain  this  end  by  making  salient  and  well-defined  groups. 
Too  much  multiplication  of  divisions  brings  confusion. 

189) 


IQO  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

Almost  all  autliors  have  acknowledged  the  division  into  pri- 
mary and  secondary  pharyngitis.  But  just  as  I  have  shown 
for  diphtheria  in  general,  secondary  pharyngitis  usually  as- 
sumes the  infectious  form.  This  grouping  has  thus  only  an 
etiological  value.  I  do  not  deem  it  worth  while  to  regard  it 
in  the  description  of  the  symptoms. 

Benign  Diphtheritic  Pliaryngitis. — The  onset  is  sometimes 
announced  by  a  slightly  marked  febrile  movement  preceded 
by  slight  rigors.  The  temperature  does  not  exceed  38°  or 
38.5°  (ioo.6°-iOi.3°  F.),  the  pulse  remains  at  about  120  in 
children,  but  below  that  number  in  adults.  To  this  movement 
there  are  added  anorexia,  and  quite  intense  headache,  accom- 
panied by  fatigue,  and  pain  in  the  back.  Upon  the  same  day 
or  the  next  the  patient  complains,  if  he  be  old  enough  to  ex- 
press himself,  of  a  pain  in  the  fauces  which  may  be  very  in- 
tense, but  is  often  moderate.  It  is  perceived,  at  the  begin- 
ning, only  during  deglutition,  then  it  augments,  manifesting 
itself  by  a  feeling  of  heat,  of  warmth,  of  dryness,  or  of  a  for- 
eign body  in  the  fauces,  or  further,  by  pain  seated  at  the  an- 
gle of  the  jaw.  If  the  patient  be  very  young  he  shows  the 
sense  of  pain  only  by  refusing  to  swallow,  and  sometimes 
even  the  dysphagia  may  be  also  lacking. 

Examination  of  the  fauces  shows  from  the  first  a  more  or 
less  lively  redness  of  the  pharynx.  The  two  tonsils,  more 
often  one  only,  are  swollen,  and  the  swelling  extends  to  the 
corresponding  pillars.  Soon  there  appears  upon  the  diseased 
part  an  opal  white  spot,  thin,  transparent,  well  circumscribed, 
and  resembling  coagulated  mucus.  Such  is  the  false  mem- 
brane at  its  entrance  upon  the  scene.  It  thickens  without  de- 
lay and  becomes  opaque  and  of  a  white  color,  which  at  once 
gives  it  a  resemblance  to  cooked  white  of  &%g,  but  it  becomes 
yellowish  afterward.  It  is  sharply  circumscribed,  thicker  in 
the  centre  than  at  the  edges,  and  its  white  color  contrasts 
sharply  with  the  red  ground  of  the  mucous  membrane. 

But  slightly  adherent  at  the  beginning,  it  can  be  lifted  off, 
holding  fragments  of  epithelium  attached  to  its  under  side,  but 
later  the  connection   becomes   more   intimate ;   it   resists   trac- 


LOCALIZATION   OF   IMrHTHERIA.  ^  I9I 

tion,  and  cannot  be  torn  off  without  the  mucous  membrar.e 
bleeding. 

Usually  single,  and  of  the  size  of  a  lentil,  it  gradually  in- 
creases in  size.  Its  habitual  extension  is  quite  limited,  reach- 
ing but  little  beyond  the  tonsil  upon  which  it  originated.  Yet 
it  may  spread  beyond  it  and  send  the  projections  along  the 
neighboring  pillars,  along  the  free  edge  of  the  velum  palati, 
and  along  the  side  of  the  uvula.  These  extensions  thin  out  in 
proportion  as  they  depart  from  their  point  of  origin,  and  when 
they  have  reached  the  uvula  form  only  a  raised  edge,  some- 
times scarcely  perceptible.  Finally  the  opposite  tonsil  may 
be  attacked  in  its  turn,  rarely  at  the  same  time  as  the  first. 
Such  is  the  aspect  of  the  exudate  in  the  greater  number  of 
cases,  corresponding  with  the  majority  of  the  known  de- 
scriptions. 

But  this  aspect  is  far  from  being  immutable.  In  place  of 
being  single  and  forming  a  large  patch  spread  out  upon  the 
tonsil,  the  false  membrane  appears  under  the  form  of  white  or 
yellow  points  the  size  of  millet  seed,  with  sharply  bounded 
contour  and  flat  surface,  from  three  to  six  in  number,  and  sep- 
arated by  the  reddened  mucous  membrane.  These  spots  may 
remain  discrete,  but  oftener  they  spread  and  unite,  either  all 
together,  so  as  to  form  a  single  patch,  or  in  groups.  These 
points  have  no  resemblance  to  the  white,  rounded,  salient, 
caseous  concretions  which  form  in  the  lacunae  of  the  tonsils  in 
the  absence  of  any  morbid  condition,  accompanied  neither  by 
redness  of  the  mucous  membrane  nor  by  pain,  nor  by  any 
sympton  of  pharyngitis. 

This  form  of  diphtheritic  pharyngitis  is  very  important  to 
recognize.  We  are  often  brought  to  consider  this,  under  the 
name  of  herpetic  pharyngitis,  as  a  separate  species.  The  gen- 
eral symptoms  and  all  the  accidents  of  diphtheria  which  ac- 
company it  in  certain  cases  give  a  sharp  contradiction  to  that 
view. 

This  exception  to  the  habitual  behavior  of  the  false  mem- 
brane is  not  the  only  one.  Diphtheria  is  Proteus  like  in  its  be- 
ginning :  it  is  impossible  to  assign  it  a  pathognomonic  local  form. 


192  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

It  is  the  sum  total  of  the  complex  morbid  phenomena  and  not 
the  outward  aspect  of  the  product,  which  specifies  it.  We  can 
lay  it  down  as  a  principle  that :  diphtheria  begins  with  the  most 
varied  local  phenonieyia,  a?id  that  the  form  and  the  disposition  of 
the  false  membranes  do  not  snfjice  to  enable  its  to  prejudge  either 
the  nature  or  the  prognosis  of  the  disease.  This  aphorism  is  one 
of  the  most  important  in  the  doctrine  of  diphtheria,  and  I  shall 
have  occasion  to  emphasize  it  more  than  once. 

Whatever  be  its  form  and  its  disposition  the  false  membrane 
has  little  tendency  to  spread.  It  may  indeed  gain  a  little  ter- 
ritory, and  even  seize  upon  other  portions  of  the  fauces  or  of 
the  mouth,  but  it  has  little  disposition  to  become  general  or  to 
appear  upon  other  organs.  It  does  not  extend  into  the  nasal 
fossae,  but  it  may  descend  into  the  larynx  and  constitute  croup. 
This  is  one  of  the  reasons  why  it  is  indispensable  to  know  the 
local  variations  of  diphtheria  at  the  beginning.  In  default  of 
being  posted  upon  this  point  one  runs  the  risk  of  seeing  a  pa- 
tient attacked  with  croup,  concerning  whom  he  has  made  the 
diagnosis  of  herpetic  pharyngitis  or  ordinary  diphtheritic 
pharyngitis. 

The  mucous  membrane  is  red  and  swollen.  It  projects  a 
little  over  the  false  membrane,  which  appears  as  in  a  setting. 
Under  the  exudate  it  is  red,  but  neither  ulcerated  nor  gan- 
grenous. 

The  submaxillary  ganglia  are  slightly  swollen,  they  form  lit- 
tle hard  kernels,  slightly  painful,  which  roll  under  the  finger. 
The  surrounding  cellular  tissue  does  not  participate  in  the 
swelling. 

Albuminuria  is  not  very  rare. 

The  course  of  this  pharyngitis  is  neither  long  nor  severe. 
After  a  few  days,  from  three  to  eight,  the  false  membranes  be- 
come detatched  at  the  borders,  which  lift  up  ;  they  retract,  as- 
sume a  darker  hue  and  fall  off  all  in  one  piece  or  in  fragments, 
or  disappear,  by  attrition.  The  fauces  become  clean  and  the 
mucous  membrane  soon  recovers  its  normal  color.  At  the 
same  time  the  functional  troubles  cease,  the  dysphagia  is  al- 
layed at  the  end  of  three  or   four   days  ;  the   fever,  which   had 


LOCALIZATION    OF    DIPHTHERIA.  I93 

never  been  intense,  vanishes  ;  the  headache  and  backache  dis- 
appear, the  tongue  clears  off,  the  appetite  returns  and  the  ade- 
nitis undergoes  resolution.  Recovery  is  attained  after  a  short 
convalescence. 

The  entire  duration  does  not  exceed  eight  or  ten  days.  I 
have  seen  the  false  membrane  fall  off  on  the  fifth  day  and  re- 
covery become  complete  on  the  sixth. 

But  if,  in  spite  of  the  benign  character  of  the  disease,  the 
false  membrane  descends  into  the  larynx,  which  usually  hap- 
pens at  the  end  of  three,  four  or  five  days,  at  the  same  time 
when  it  begins  to  loosen  in  the  fauces,  the  disease  is  found 
to  be  modified,  and  follows  the  phases  of  the  laryngeal  affec- 
tion. 

Diphtheritic  paralysis  may  be  the  consequence  of  this  phar- 
yngitis. 

Infectious  Diphtheritic  Pharyngitis. — The  beginning  is  much 
the  same  as  in  the  benign  form.  A  little  more  intensity,  and 
especially  of  duration,  in  the  general  symptoms,  make  the  dif- 
ference between  the  two  conditions.  The  initial  chill,  without 
being  violent,  is  more  constant  and  oftener  repeated ;  besides, 
vomiting,  diarrhoea,  and  even  convulsions,  may  be  added  to  the 
train  of  symptoms. 

The  fever  is  more  intense,  the  pulse  exceeds  120,  the  tem- 
perature remains  in  the  neighborhood  of  38. °5  (101°  F.),  while 
it  may  reach  39°  (i02.°2  F.). 

The  fauces  are  more  painful,  they  are  dry  and  burning,  and 
the  dysphagia  is  very  marked. 

Examination  of  the  back  part  of  the  mouth  reveals  a  lively 
redness  and  a  general  swelling,  more  marked  at  first,  however, 
upon  one  side. 

The  false  membrane  appears  as  before  in  from  twelve  to 
thirty-six  hours  at  the  farthest,  from  the  first  onset.  But  there 
the  analogy  between  the  two  forms  ceases. 

In  certain  cases  the  beginning  is  insidious.  It  is  that  of  ca- 
tarrhal pharyngitis,  remaining  such  for  one,  two  or  three  days, 
when  the  diphtheria  throws  off  the  mask  by  the  appearance  of 
the  false  membrane. 


194  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

One  tonsil  only  is  at  first  attacked,  but  the  other  without  de- 
lay becomes  covered  with  the  exudate,  as  well  as  the  pillars, 
the  uvula,  the  pharynx,  the  velum  palati ;  and  it  is  not  rare  to 
see  patches  appearing  along  the  internal  surface  of  the  cheeks, 
along  the  tongue,  the  commissure  and  the  internal  aspect  of 
the  lips.  This  remarkable  power  to  become  general  is  the 
truly  characteristic  feature  of  this  form  of  pharyngitis,  for  not 
only  does  the  false  membrane  extend  rapidly  over  contiguous 
regions,  but  it  springs  up  in  the  most  distant  parts. 

Still  other  important  modifications  in  the  behavior  of  the 
exudate  mark  this  form.  It  is  thick,  salient,  and  formed  of 
stratified  layers  which  augment  each  day  and  of  which  the 
oldest  are  the  most  firm  and  the  most  resistant.  I  have  shown 
in  the  pathological  anatomy  what  degree  of  thickness  and  of 
resistance  it  may  acquire.  The  surface  is  no  longer  smooth 
but  roughened.  The  contours,  instead  of  being  rounded  are 
irregular  and  fissured.  Its  color,  at  first  white,  changes  rapidly, 
passing  to  yellow,  gray,  and  then  to  dark  gray. 

The  mucous  membrane  becomes  purple  and  bleeding.  Un- 
der the  influence  of  the  oozing  of  blood  and  of  contact  with 
food  the  false  membrane  assumes  a  brown  or  blackish  tint 
which  gives  it  a  gangrenous  appearance,  rendered  still  more 
striking  by  a  repulsive  fetor.  It  is  not  astonishing  that  it  was 
long  thought  to  be  an  eschar  and  that  this  form  of  pharyngitis 
received  the  name  of  angina  gangrenosa.  Yet  such  is  not  the 
case,  at  least  in  a  majority  of  instances.  As  Bretonneau  has 
shown,  the  mucous  membrane  is  either  healthy,  or  barely  ex- 
coriated underneath  the  concretion.  There  is  quite  an  impos- 
ing number  of  cases  in  which  the  violence  of  the  inflammatory 
process  brought  on  a  veritable  necrosis.  Gangrenous  or  not, 
the  fauces  present  a  characteristic  appearance.  The  back  part 
appears  to  be  brought  nearer  the  opening  of  the  mouth,  the 
pillars,  considerably  swollen,  approximate  and  conceal  the 
pharynx  ;  the  tonsils,  voluminous  and  globular,  are  enormous, 
the  uvula  distended,  elongated  and  deformed,  hangs  in  front  of 
the  pillars;  it  may  also  be  engaged  between  them  or  deviate 
to  one  side  or  the  other,  and  it  is  covered  with  a  pseudo-mem- 


LOCALIZATION  OF   DIPHTHEKIA.  I95 

branous  cap  which  resembles,  according  to  a  picturesque  and 
exact  comparison,  the  finger  of  a  glove. 

From  the  mouth  there  exudes  an  abundant  sanious  secre- 
tion, exhaling  the  same  odor.  Deglutition  is  difficult,  for  the 
pain  often  renders  it  incomplete,  and  foods  are  in  part  rejected. 
Liquids  alone  can  be  ingested. 

The  swollen  nasal  mucous  membrane,  in  its  turn  often  cov- 
ered with  false  membrane,  does  not  permit  the  passage  of  air. 
The  patient  breathes  through  his  mouth,  v/hich  he  keeps  open. 
Respiration  is  completely  performed ;  the  air  penetrates  fully 
into  the  chest,  but  in  its  passage  it  sets  in  vibration  the  velum 
palati  and  the  back  portions  of  the  fauces,  which  have  become 
relaxed.  There  results  a  snoring  stertorous  noise.  The  voice 
is  nasal. 

The  submaxillary  ganglia  rapidly  enlarge  to  a  considerable 
degree,  the  inflammation  extends  to  the  surrounding  connect- 
ive tissue,  whence  follows  an  oedema  which  makes  the  skin 
tense  and  shining,  and  a  quite  characteristic  pyriform  aspect 
of  the  head  is  produced  by  the  swelling  of  the  neck.  I  shall, 
at  the  end  of  this  chapter,  return  to  the  adenitis,  a  full  de- 
scription of  which  would  occasion  too  long  a  digression. 

The  tongue  is  foul  and  slimy.  The  patient  refuses  food, 
even  those  kinds  of  which  he  is  most  fond,  as  much  from  en- 
tire absence  of  appetite  as  from  fear  of  pain.  Constipation  is 
frequent.     The  fever  continues  without  increasing. 

Sleep  is  often  interrupted  by  the  necessity  of  expectoration. 
Yet  the  strength  is  pretty  well  preserved,  and  the  countenance 
presents  only  a  certain  degree  of  pallor.  The  patient  sits  up 
in  bed,  his  mouth  half  open,  wiping  his  lips  whence  saliva 
freely  exudes,  mixed  with  the  faucal  secretion. 

Examination  of  the  urine  discloses,  according  to  the  case,  a 
certain  quantitity  of  albumen.  ' 

At  this  time  other  pseudo-membranous  manifestations  affect 
different  points  in  the  economy.  The  most  frequent  of  all  is 
that  which  attacks  the  nasal  mucous  membrane.  A  discharge, 
mucous  at  first,  then  serous  and  sero-sanguinolent,  escapes, 
from  one  of  the  nostrils,  the  skin  grows   red,   and,  opening  the 


196  DJI'IITHERIA,    CROUP    AND    TRACHEOTOMY. 

nostril,  a  lalse  membrane  appears,  situated  close  to  the  en- 
trance. In  other  cases  the  exudate  is  not  seen;  it  forms  about 
the  posterior  opening  or  in  the  cavity  of  the  nasal  fossae,  the 
discharge  alone  revealing  its  presence. 

Then  comes  the  extension  toward  the  larynx  announced  by 
roughness  of  the  cough  and  of  the  voice.  Wounds,  excoria- 
tions, ulcers,  cutaneous  folds  where  the  skin  is  so  delicate  in 
children,  the  Eustachian  tube  and  the  middle  ear,  the  oesopha- 
gus, the  anus,  and  sometimes  the  intestine,  and  finally  the 
genital  organs  may  be  invaded,  all  together  or  separately. 

Having  come  to  this  point  in  the  disease,  i.  e.,  at  the  end  of 
from  five  to  seven  days,  the  patient  may  recover. 

Then  the  fever  goes  down,  the  false  membranes  cease  to  re- 
form, not  only  in  the  fauces  but  in  the  nose,  upon  the  skin  and 
upon  the  mucous  surfaces.  They  become  detached  at  their  bor- 
ders, and  are  eliminated  as  in  the  preceding  form,  either  entire 
or  in  fragments,  or  by  molecular  disintegration.  Their  exfoli- 
ation begins  from  the  second  to  the  tenth  day  and  ends  from 
the  fifth  to  the  fifteenth,  sometimes  later ;  not  being  complete 
in  one  case  till  the  twenty-fifth  day.  The  swelling  of  the 
fauces  subsides,  the  odor  grows  less  and  disappears  and  the 
nose  ceases  discharging.  The  hoarse  cough  ceases,  the  aden- 
itis undergoes  resolution,  the  swelling  subsides,  and  the  head 
by  degrees  resumes  its  form.  Sleep  improves  and  appetite  re- 
turns. Alimentation,  however,  still  remains  difficult,  because 
the  sensitiveness  of  the  mucous  membrane  persists  till  the 
newly-formed  epithelium  has  attained  its  normal  consistence. 

When  the  issue  is  to  be  fatal  many  paths  may  lead  thereto. 
The  most  common  is  the  propagation  of  the  false  membrane 
into  the  larynx,  resulting  in  croup  and  death  by  suffocation. 

But  the  pharyngitis  also  causes  death  by  the  intensity  alone 
of  the  infection.  The  false  membranes,  instead  of  diminishing, 
remain  stationary  or  augment,  either  by  reproduction  in  situ 
or  by  occupation  of  other  surfaces,  the  tongue,  the  cheeks,  the 
lips,  the  nose,  the  skin,  etc.  The  fetor  increases,  the  sanious 
secretion,  which  forms  about  the  false  membranes,  becomes 
more  abundant.     Rejected  in  part,  but  in  part  absorbed  by  the 


LOCALIZATION  OF  DIPHTHERIA.  I97 

digestive  tract  or  by  surfaces  denuded  of  epithelium,  it  be 
comes  a  new  source  of  infection  to  the  patient,  not  of  diphthe- 
ritic poisoning,  as  Bretonneau,  supported  also  by  Bouchut,  has 
claimed — this  poisoning  is,  once  for  all,  rather  of  putrid  in- 
fection. The  diseased  parts  may  then  become  the  seat  of  true 
gangrene.  The  tissues  assume  a  dark  green  tint.  Eschars 
are  formed  which,  if  they  have  time  to  loosen,  leave  behind 
them  considerable  loss  of  substance,  destroy  the  uvula,  re- 
move large  portions  of  the  tonsils,  and  may  even,  as  I  have 
observed  in  one  case,  perforate  the  velum  palati  in  one  or  more 
points.  [I  treated  the  case  of  a  girl  with  diphtheria,  in  1857, 
about  five  years  old — Hoffman — who  suffered  a  perforation  of 
the  veil  of  the  palate.  The  hole  was  elliptical  in  shape ;  and 
it  has  never  closed,  but  does  not  seem  to  cause  any  inconven- 
ience. She  had  a  second  attack  about  two  years  ago  (after  about 
twenty-five  years)  which  seems  rather  to  have  enlarged  the 
hole.  My  friend,  Dr.  S.  W.  Ranney,  of  Hope,  Ohio,  did  me 
the  kindness  to  report  the  second  attack.]  An  almost  ir- 
resistible tendency  toward  ulceration  is  shown  at  other  points, 
the  skin,  the  lips,  etc.,  wherever  false  membranes  exist. 

The  nose  becomes  the  seat  of  a  sero-sanguinolent  discharge 
of  a  repulsive  odor.  False  membranes  project  from  its  orifice, 
and  extend  down  upon  the  upper  lip.  Epistaxis,  often  severe 
and  repeated,  occurs,  and  other  haemorrhages  arise  from  the 
mouth,  the  stomach,  the  anus  and  the  bladder.  The  buccal 
mucous  membrane  is  purple  and  bleeding  and  the  false  mem- 
branes are  colored  brown.  The  submaxillary  swelling  in 
creases,  and  at  times  reaches  suppuration.  The  dysphagia 
also  increases  and  renders  alimentation  impossible.  The  fe- 
ver persists,  rising  to  39°  and  40°  C.  (102-104'^  F.),  The  face 
grows  pale,  becoming  lead-colored.  The  mucous  membranes 
assume  a  bluish  tint  without  there  being  asphyxia.  The  ex- 
pression of  countenance  is  sad,  downcast  or  indifferent.  The 
features  are  drawn.  The  eyes  are  expressionless  and  encir- 
cled a  with  dark  ring.  Intelligence,  however,  remains  perfect. 
Sleep  is  nil ;  strength  diminishes  and  diarrhoea  sometimes  su- 
pervenes. Albuminuria  persists  or  ceases.  Finally  the  pa- 
tient dies  in  a  state  of  marasmus. 


198  DIPHTHERIA,    CROUl'    AND    TRACHEOTOMY. 

The  duration  of  this  pharyngitis  is  long.  Aside  from  the 
cases  where  death  comes  on  about  the  fifth  day,  it  occurs 
oftencst  about  the  tenth  or  twelfth ;  I  have  observed  cases  in 
which  death  has  been  delayed  till  the  sixteenth,  the  twenty- 
first,  and  even  the  twenty-seventh  day. 

Even  when  recovery  takes  place  it  may  last  for  twenty-five 
or  thirty  days  exclusive  of  the  paralysis  which  may  follow  it. 
It  is  to  this  form  that  those  cases  belong  which  Barthez  and 
Isambert  cite  and  which  lasted  several  months  and  which 
prompted  in  Barthez  the  thought  of  admitting  a  chronic   form. 

The  adenitis  deserves  a  separate  mention.  It  usually  affects 
a  large  number  of  ganglia.  Swollen,  painful  and  rolling  under 
the  finger  they  early  form  a  voluminous  mammillated  mass.  But 
the  cellular  envelop  is  attacked  in  its  turn,  it  thickens  and  soon 
conceals  the  inequalities  of  the  glands.  Painful  to  the  touch 
and  giving  a  sensation  of  puffiness  on  pressure,  the  skin  retains 
the  imprint  of  the  fingers.  It  is  tense  and  smooth,  but  retains 
its  usual  color. 

The  region  then  becomes  enlarged  and  uniform,  the  swelling 
effaces  the  angle  of  the  jaw  and  often  extends  beyond  it  to 
reach  the  lower  part  of  the  face  or  the  superhyoid  region. 
When  both  sides  are  involved  the  lower  part  of  the  face  be- 
comes considerably  increased  in  its  transverse  diameter;  the 
head  thus  deformed  assuming  a  pyriform  appearance. 

If  the  patient  recover,  resolution  may  occur,  the  swelling 
subsiding  from  without  inward.  The  skin  becomes  less  tense, 
the  subjacent  tissues  relax  and  grow  thinner,  the  nodosities  of 
the  ganglia  begin  to  be  felt.  Soon  the  mass  becomes  dispersed, 
broken  upas  it  were,  the  glands  reappear  from  the  matrix  that 
enclosed  them,  and  resolution  goes  on  little  by  little  until  the 
return  to  the  normal  condition.  But,  in  place  of  diminishing, 
the  submaxillary  swelling  may  increase.  If  it  be  on  both  sides 
it  passes  beneath  the  jaw,  invades  the  anterior  portion  of  the 
neck  and  gives  rise  to  symptoms  of  compression  of  the  trachea. 
Suppuration  is  speedy.  The  softening  is  perceived  first  at  one 
point,  then  at  others  and  reaches  the  entire  mass.  A  well-di- 
rected but  difficult  treatment  usually  results  in  cure. 


LOCALIZATION    OF    DIPHTHERIA.  I99 

It  is  to  be  noted  that  the  violence  of  the  adenitis  does  not 
always  coincide  with  the  severe  stage  of  the  pharyngitis.  It 
may  appear  in  an  unexpected  manner  when  the  pharyngitis  is 
almost  well,  and  when  the  false  membrane  has  altogether  dis- 
appeared, even  in  cases  in  which  the  adenitis  was  moderate 
during  the  height  of  the  pharyngitis.  We  then  see  the  fever 
relighted  at  the  very  time  when  convalescence  seemed  to  be 
beginning,  and  the  adenitis  return  with  violence.  Suppuration 
of  the  glands  brings  with  it  all  the  symptoms  incident  to  ab- 
scesses of  the  neck,  viz.:  burrowing  of  pus  beneath  the  fascia, 
compression  of  important  organs,  etc. 

In  one  case  the  pus  had  burrowed  behind  the  pharynx  and 
had  formed  in  that  region  an  enormous  abscess  which  opened 
spontaneously.  A  continuous  bloody  discharge  oozed  from  the 
mouth  and  from  the  nose,  when,  about  the  sixth  day,  a  furious 
haemorrhage  bursting  from  the  nose  and  mouth,  carried  the  pa- 
tient off  in  a  moment.  The  autopsy  showed  that  this  haemor- 
rhage had  its  origin  in  the  retro-pharyngeal  center. 

Malignant  DipJitheritic  Pharyngitis — This  form  is  the  ex- 
pression of  diphtheritic  poisoning  carried  to  its  highest  degree. 
The  infection  holds  the  first  place,  while  the  pharyngitis  is 
relegated  to  the  second.  I  shall,  then,  have  to  recur  in  great 
measure  to  what  I  have  said  of  the  malignant  form  of  diph- 
theria. 

This  species  includes  two  varieties,  a  fulminating  form  and 
an  insidious  form. 

Fulminating  [Explosive)  Form. — All  the  morbid  symptoms 
which  pertain  to  the  severe  form  of  infectious  pharygitis  re- 
appear here,  but  with  frightful  rapidity.  After  a  rigor,  slight, 
but  repeated,  after  some  epistaxis  which  often  marks  the  onset, 
general  symptoms  develop,  and  then  the  pharyngitis  appears, 
taking  on  a  gangrenous  or  pseudo-membranous  character  al- 
most from  the  first  onset.  The  nose  is  prematurely  invaded. 
The  adenitis  comes  on  early.  The  surrounding  cellular  tissue 
swells  considerably,  but  without  the  oedematous  doughy  feel, 
it  retains,  on  the  contrary,  a  flabby  consistence. 

If  the  false  membranes  take  on  a  gangrenous  appearance 


200  DIPHTHERIA,    CROUP    AND    TRACHKOTOMY, 

and  odor;  if  the  mucous  membrane  is  purple  and  bleeding, 
we  need  not  think  that  the  exudate  has  always  a  very  great  ten- 
dency toward  propagation.  Admitting  that  it  may  show  itself 
at  the  same  time  in  the  nasal  fossae,  and  that  it  may  rapidly  in- 
vade the  larynx,  it  is  often  hmited,  and  it  may  occupy  but  one 
side  of  the  fauces,  and  that  only  partially,  and  be  reduced  to 
insignificant  proportions. 

The  appetite  is  nil ;  there  is  extreme  weakness ;  the  patient 
is  as  though  dazed.  In  many  cases  I  have  noted  an  invincible 
somnolence,  sometimes  even  coma.  The  fever  of  the  first  day 
rapidly  gives  place  to  collapse.  The  pulse  grows  slower,  fall- 
ing to  60,  40,  and  even  less.  It  becomes  small,  thready,  and 
imperceptible.  Hsemorrhages  arise  from  various  points,  or 
are  limited  to  a  continual  oozing  from  the  mouth.  The  ex- 
tremities grow  cold ;  the  temperature  falls  below  36°  (97°  F.), 
and  the  patient  succumbs.  A  mild  delirium  sometimes  termi- 
nates the  scene,  but  somnolence  and  coma  are  the  more  usual 
signs.  The  urine  contains  albumen,  but  not  in  every  case. 
Two,  or  at  most  three  days,  sometimes  suffice  for  the  evolu- 
tion of  this  pathological  drama. 

The  insidious  form  presents  special  characters  which  I  have 
sufficiently  developed  in  describing  the  insidious  form  of 
diphtheria  in  general.  I  could  not  go  over  them  without  repe- 
tition. It  will  be  enough  for  me  to  still  insist  on  the  deceptive 
mildness  which  marks  its  beginning  upon  the  slight  extent  of 
the  false  membrane,  which  sometimes  presents  the  arrange- 
ment in  points  attributed  to  herpetic  pharjmgitis.  One  sign, 
however,  will  put  the  physician  on  his  guard,  and  will  enable 
him  to  avoid  error ;  it  is  the  swelling  of  the  neck,  that  enor- 
mous, flabby  swelling  in  which  the  cellular  tissue  participates 
more  than  the  glands,  a  swelling  out  of  all  proportion  to  the 
local  condition,  and  which  Trousseau  said,  savors  of  its  pesti- 
lence [sent  sa  peste).  Death,  the  unavoidable  termination, 
comes  on  in  from  six  to  ten  days. 

Albuminuria  is  a  frequent  but  not  a  necessary  concomitant 
of  this  condition. 

It  may  be  worth  while  to  note  a  variation  which  sometimes 


LOCALIZATION  OF    DIPHTHERIA.  20I 

marks  the  beginning.  The  patient  complains  of  a  violent  pain 
in  the  fauces  which  nothing  in  sight  accounts  for.  Then  there 
appears  a  slight  swelling  about  the  angles  of  the  jaw  quickly- 
followed  by  the  sudden  and  simultaneous  explosion  of  the  false 
membrane,  the  enormous  submaxillary  swelling,  and  general 
symptoms. 

Section  2 — Croup. 

Designated  by  ancient  authors  under  different  names  sug- 
gested by  the  principal  symptom  of  the  disease,  laryngeal 
diphtheria  was  called:  "Morbus  strangulatorius"  (Sgambati, 
Carnevale,  Cortesio,  Marcus  A.  Severinus,  etc.),  garotillo  (Perez 
Casales),  "angina  laryngea  exudatoria"  (Hufeland),  ''morbus 
truculentus  infantum"  (Van  Bergen),  "diphtheric  tracheale" 
(Bretonneau),  and  laryngite  pseudo-membraneuse  "pseudo- 
membranous laryngits"  a  name  adopted  by  several  modem 
authors.  But  in  our  day  it  still  retains  the  popular  denomina- 
tion of  croup,  applied  to  it  by  Home.  Like  angina,  croup  may 
take  on  one  or  another  of  the  three  forms  of  diphtheria.  But 
the  local  condition  has  much  more  importance  than  in  angina ; 
the  false  membrane  which  obstructs  the  larynx  asphyxiates  the 
patient,  however  slight  the  diphtheritic  poisoning  may  be.  It 
appears,  therefore,  difficult  to  admit  a  benign  form  of  croup,  a 
morbid  condition  which,  left  to  itself,  is  too  often  fatal.  There 
comes,  however,  a  time  when  the  benignity  returns  and  claims 
its  rights.  Let  an  effort  of  nature  expel  the  false  membrane, 
or  tracheotomy  interpose  and  terminate  the  asphyxia,  then  the 
disease  follows  a  very  simple  course,  and  recovery  is  soon  at- 
tained. One  may,  therefore,  accept  without  paradox,  a  benign 
form  of  croup. 

All  authors  admit  a  primary,  and  a  secondary  form.  I  be- 
lieve this  division  no  more  justified  for  croup  than  for  angina ; 
secondary  croup  assumes  the  infectious  form,  and  sometimes 
the  malignant,  and  follows  a  course,  under  these  circumstances, 
as  if  it  were  primary.  Certain  differences  in  its  course,  dis- 
tinguish croup  of  adults  from  that  of  children. 

The    beginning   sometimes    presents    certain    general    signs 


202  DIPHTHERIA,    CROUP    AND    Tl<  ACll  liOTOMY. 

which  we  have  found  in  all  the  manifestations  of  diphtheria, 
viz.,  slight  chill,  moderate  fever  or  more  commonly  none,  some- 
times, however,  quite  intense;  vomiting,  convulsions,  general 
discomfort,  headache  and  lassitude.  The  laryngeal  symptoms 
appear  afterwards.  But  it  is  only  in  exceptional  cases  that  this 
course  of  events  occurs  ;  in  the  great  majority  croup  is  preceded 
by  diphtheritic  angina  or  a  coryza  of  the  same  nature.  Bre- 
tonneau  and  Guersant  gave  it  as  an  absolute  rule.  Numerous 
observers,  viz.,  Trousseau,  Rilliet  and  Barthez,  Blondeau,  J. 
Bergeron  and  Hache,  have  proved  that  diphtheria  may  com- 
mence in  the  larynx,  and  that  croup  may  exist  primarily — 
d'emblce.  Some  of  them  have  admitted  that  the  larynx  was  oc- 
casionally invaded  after  the  bronchi.  Rilliet  :ind  Hache  have 
seen  the  larynx  attacked  first  in  a  large  number  of  cases.  Ril- 
liet adds  :  "In  half  of  the  cases  the  false  membrane  developed  in 
the  pharynx  subsequently  to  the  laryngeal  symptoms." 

Vauthier  has  seen  angina  fail  in  half  of  the  cases.  Bergeron 
has  proved  that  it  was  absent  in  about  one-third.  J.  Simon 
accepts  this  opinion,  and  estimates  with  Guersant  that  primary 
croup  is  observed  in  one  twentieth  of  the  cases. 

My  conclusions  conform  to  those  of  the  above  observers. 
Croup  may  exist  primarily,  that  is  to  say,  the  false  membrane 
may  be  deposited  in  the  first  place  upon  the  larynx ;  but  one  is 
correct  in  making  the  assertion  only  in  the  cases  in  which  the 
disease  has  been  followed  from  the  beginning  and  when  it  has 
been  possible  to  examine  the  throat  and  the  nares  every  day. 
It  is  necessary,  indeed,  to  bear  in  mind  the  circumstances 
under  which  the  false  membrane  has  rapidly  extended  from 
the  throat  to  the  larynx,  and  those  under  which  the  angina — 
not  having  been  intense,  has  not  attracted  attention,  so  that 
at  the  moment  when  the  laryngeal  symptoms  arise,  the  gut- 
tural false  membrane  has  disappeared.  Certain  autopsies  have 
indicated  to  me  another  cause  of  error  sufficiently  curious,  of 
which  it  is  important  to  take  an  account.  In  subjects  dead  of 
croup  without  apparent  angina,  in  spite  of  attentively  examin- 
ing the  throat,  I  have  found  false  membranes  seated  on  the 
posterior  face  of  the   tonsils  and  extending  thence  towards  the 


LOCALIZATION    OF    DIPHTHERIA.  2O3 

larynx.  The  anterior  face  of  the  tonsils  was  sound,  as  well  as 
the  pillars.  One  sees,  therefore,  the  restriction  which,  for  fear 
of  error,  is  placed  upon  the  observer.  It  reduces  the  number 
of  cases  of  primary  croup. 

However,  there  are  cases  in  which  the  false  membrane  com- 
mences evidently  in  the  larynx  or  in  the  bronchi.  A  hoarse 
cough,  dyspnoea,  paroxysms  of  suffocation  and  even  expulsion 
of  false  membranes  coming  from  the  larynx  or  from  the  trachea 
or  bronchi ;  such  are  the  symptoms  of  the  disease ;  and,  ex- 
amined regularly  from  the  beginning,  the  throat  has  at  all  times 
been  clear.  This  course  is  still  more  significant,  when,  after 
the  expulsion  of  false  membranes,  an  exudate  appears  upon  the 
tonsils,  as  Rilliet  has  frequently  observed.     That  is  really  the 

CROUP    ASCENDENS. 

The  estimate  that  I  have  made  of  the  relative  frequency  of 
primary  or  ascending  croup  is  still  larger  than  that  of  Simon. 
Croup  commenced  primarily  in  one-eighth  of  the  cases.  In 
1172  cases  of  croup  the  starting  point  was  142  times  in  the 
larynx.  I  refrain,  however,  from  giving  to  these  figures  a  pos- 
itive value;  it  is  made  largely  from  observations  made  at  hos- 
pitals, and  is  quite  open  to  the  objections  that  I  have  raised. 

Considerable  variations  depend  also  upon  epidemics.  Bre- 
tonneau  considered  coryza  as  always  preceding  croup  and  even 
angina.  This  fact,  which  attracted  the  attention  of  the  dis- 
tinguished physician  of  Tours  in  the  epidemics  which  passed 
under  his  observation,  has  not  been  verified  since,  at  least  in  a 
general  and  constant  manner.  The  nose  is  often  attacked  at 
the  same  time  as  the  throat,  in  the  infectious  form ;  and  some- 
times before,  but  most  frequently  the  throat  is  the  stage  on 
which  it  makes  its  debut. 

When  angina  precedes  croup,  one  sees  evolved  the  pathologi 
cal  whole  which  has  been  described  above.     Special  symptoms 
announce  the  entrance  of  the  false  membrane  into  the  larynx. 
When   croup   presents    itself  primarily,    these    symptoms    an- 
nounce its  onset. 

Jn  very   rare  cases  in  which  croup  shows  itself  subsequently 


204  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

to  tracheal  or  bronchial  diphtheria  these  same  symptoms  are 
preceded  by  thoracic  symptoms,  by  phenomena  furnished  by 
auscultation.  The  only  symptom,  the  semeiological  value  of 
which  is  certain,  is  the  expulsion  of  false  membranes  ramified 
or  in  bands  the  form  of  which  may  prove  their  tracheal  or 
bronchial  origin. 

The  larynx  once  invaded,  the  local  affection  takes  supremacy, 
the  respiratory  affection  occupies  the  first  rank,  the  poisoning, 
at  least  when  it  is  not  very  profound,  remains  in  the  second. 

The  respiratory  symptoms  may  be  divided,  as  proposed  by 
Barthez,  into  three  periods. 

The  first  presents  only  laryngeal  symptoms  without  as- 
phyxia; the  second  is  characterized  by  paroxysms  of  suffoca- 
tion between  which  the  respiration  is  free  or  moderately  im- 
peded, but  without  symptoms  of  asphyxia ;  the  third  is  marked 
by  the  cessation  of  the  suffocative  attacks,  and  by  the  estab- 
lishment of  a  continued  ("enduring")  and  progressive  dyspnoea 
accompanied  by  increasing  asphyxia. 

First  Period. — The  first  local  symptom  of  croup  is  a  slight 
dry,  fitful  and  frequent  cough.  It  becomes  rapidly  rough,  hol- 
low and  suffocative,  qualities  which  distinguish  it  from  the 
ringing,  metallic  sound  of  that  which  belongs  to  stridulous 
lar^^ngitis.  Trousseau  compared  it  to  the  distant  barking  of  a 
young  dog.  It  becomes  more  hollow  in  proportion  as  the  dis- 
ease increases.  Frequent  in  the  beginning,  it  becomes  more 
and  more  rare  at  the  same  time  that  it  becomes  more  suffo- 
cative. It  ends  by  disappearing  altogether  when  the  disease 
has  reached  its  maximum  of  intensity.  The  patient  complaines 
sometimes  a  little  of  pain  in  the  region  of  the  larynx,  pain 
which  is  felt  especially  during  movements  of  the  organ,  and 
upon  pressure.  The  voice  is  also  modified ;  at  first  hoarse,  it 
becomes  coarse  and  then  diminishes,  often  to  aphonia.  These 
variations  of  sound  are  due  to  the  presence  of  false  membrane 
upon  the  lips  of  the  glottis;  the  effect  produced  is  similar  to 
that  from  a  small  piece  of  softened  parchment  placed  between 
the  reeds  of  a  clarionet  or  of  a  bassoon — (Trousseau). 

At  the  end  of  a  very   variable  time,    from    some    h©urs    to 


LOCALIZATION  OF  DIPHTHERIA.  2O5 

several  days,  the  respiration,  which  was  effected  without  diffi- 
culty, begins  to  feel  a  certain  impediment,  first  during  the 
night.  Then  there  arises  a  laryngo-tracheal  wheezing,  much 
more  marked  during  inspiration  than  during  expiration.  This 
preponderance  results  from  the  anatomical  disposition  of  the 
parts.  During  inspiration  the  lips  of  the  glottis  and  especially 
the  aryteno-epiglottic  ligaments  which  are  the  most  frequent 
seat  of  the  false  membranes,  are  drawn  into  the  lar>^ngeal 
cavity  ;the  increase  in  their  volume  brings  them  in  contact  one 
with  the  other  and  contracts  the  caliber  of  the  organ  in  pro- 
portion to  the  degree  of  their  tumefaction.  During  expiration, 
on  the  contrary,  the  column  of  air  tends  to  separate  them. 
The  ear  placed  over  the  thoracic  walls  hears  this  sound  in  all 
parts  of  the  chest  to  such  a  degree  as  in  part  to  drown  the 
respiratory  murmur.  These  respiratory  disturbances  are  al- 
ways more  marked  during  sleep. 

Second  Periods. — The  dyspnoea  progresses;  the  slight  re- 
straint of  the  first  is  followed  by  symptoms  much  more  serious, 
the  most  important  character  of  which  is  the  intermission  of 
the  dyspnoea ;  they  are  the  paroxysms  of  suffocation.  Sud- 
denly the  patient  jumps  up  in  bed,  sits  up  or  springs  out, 
clasps  his  mother  around  the  neck  a  victim  of  indescribable 
distress  and  appearing  to  implore  assistance.  He  makes  the 
most  powerful  efforts  for  breath ;  the  alse  of  the  nose  dilate, 
the  mouth  is  opened  wide,  and  the  head  and  trunk  thrown 
back.  All  the  respiratory  muscles,  those  of  the  chest  as  well 
as  those  of  the  neck,  are  brought  into  contraction ;  the  child 
aids  their  action  by  grasping  the  edge  of  his  bed  or  any  object 
to  aid  him  that  may  be  within  his  reach.  The  violent  con- 
tractions of  the  diaphragm  produces  in  the  child  a  deep  de- 
pression at  the  pit  of  the  stomach  (scrobiculus  cordis)  at  each 
inspiration,  this  peculiarity  is  explained  by  the  incomplete 
ossification  of  the  sternum  at  this  age.  The  xiphoid  cartilage, 
unable  to  resist  the  powerful  contractions  of  the  diaphragm,  is 
drawn  backward  and  upward  by  this  muscle.  The  mechan- 
ism of  the  epigastric  depression  appears  to  me  to  be  due  to 
this  cause  rather  than  to  the  production  of  the  vacuum   in  the 


206  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

thorax  which  might  draw  the  diaphragm  upwards.  If  it  were 
the  latter,  the  immovable  diaphragm  would  no  longer  repel 
the  abdominal  viscera  during  inspiration.  Now,  to  the  attentive 
observer  there  is  no  aspiration  or  traction  of  the  viscera  into 
the  thorax,  as  in  the  case  of  paralysis  of  the  diaphragm.  These 
are,  on  the  contrary,  forcibly  thrust  down  into  the  abdomen, 
and  it  is  their  decided  protrusion  which  makes  more  percepti- 
ble the  retraction  of  the  xiphoid  appendix. 

The  dyspnoea  becoming  more  intense  the  auxiliary  muscles 
come  into  action ;  the  muscles  of  the  neck  contract  energetic- 
ally, and  there  appears  at  the  superior  border  of  the  sternum 
another  depression  which  reveals  more  plainly  the  prominence 
of  the  thyroid  body.  The  totality  of  these  efforts  is  designated 
under  the  characteristic  name  of  "tirage,''  sinking  in  of  the 
soft  parts,  (retraction).  When  the  abdominal  muscles  only  are 
in  action  the  phenomenon  may  take  the  name  of  abdominal 
retraction,  {tirage  abdofninal,)  or  substernal  retraction :  when 
the  muscles  of  the  neck  come  into  line,  it  may  take  the  name 
of  cervical,  or  suprasternal  depression.  In  his  exasperation 
the  patient  grasps  at  his  throat  as  if  to  tear  away  the  obstacle 
that  chokes  him. 

Notwithstanding  all  these  efforts  the  air  enters  only  with 
difficulty,  producing  a  stridulous  wheezing  analogous  to  the 
grating  of  a  saw,  the  bruit  serratic  of  Trousseau :  the  face  be- 
comes cyanosed,  the  lips  and  the  fingers  under  the  nails  be- 
come blue;  the  skin  is  hot,  moist,  and  covered  with  profuse 
sweat ;  the  pulse  is  small,  weak,  and  exhaustion  is  complete. 

In  the  course  of  five  or  six  minutes,  occasionally  at  the  end 
of  a  quarter  of  an  hour  of  this  terrible  agony,  either  spon- 
taneously or  as  the  result  of  expulsion  of  a  fragment  of  false 
membrane,  the  respiration  becomes  gradually  easier,  less  noi- 
sy, the  cyanosis  disappears,  the  pulse  recovers,  quiet  is  re- 
stored, and  the  patient  falls  asleep.  After  this  paroxysm  the 
respiration  returns  almost  to  the  point  where  it  was  before ; 
however,  it  is  nearly  always  a  little  more  restrained. 

At  first  coming  at  rare  intervals,  the  paroxysms  become 
more  frequent.     The  first  is  often  separated  from  the  second 


LOCALIZATION   OF    DIPHTHERIA.  20/ 

by  eight  or  ten  hours,  sometimes  more  sometimes  less.  The 
interval  diminishes  later  to  two  or  three  hours,  then  to  one 
hour;  and  finally  there  may  occur  several  paroxysms  in  the 
course  of  one  hour.  In  proportion  as  they  become  more  fre- 
quent, their  violence  increases,  and  the  patient  may  even  die 
during  a  paroxysm.  They  may  return  spontaneously,  or  un- 
der the  influence  of  the  most  various  causes ;  an  effort,  a  fit  of 
anger,  fright,  cough,  the  examination  of  the  throat,  and  above 
all  cauterization.  As  relevant,  I  believe  it  proper  to  insist 
upon  the  necessity  of  being  careful  in  the  examination  of  the 
throat  in  children  sick  with  croup.  This  is  one  of  the  most 
frequent  causes  of  paroxysms  of  suffocation,  especially  if  the 
patient  resists.  Without  always  being  followed  by  such  grave 
consequences,  this  struggle  is  always  followed  by  fatigue  which 
is  very  prejudicial  to  the  patient.  This  remark  applies  also  to 
all  the  manipulations  made  about  the  throat,  as  well  in  croup 
as  in  angina. 

Third  Period — When  the  disease  follows  its  natural  course, 
the  calm  which  separates  the  fits  of  suffocation  is  replaced  by 
dyspnoea.  The  paroxysms  become  more  and  more  intense, 
and  at  shorter  intervals.  In  the  interval  the  distress  persists.  The 
dyspnoea  continues.  The  sawing  character  of  the  inspiration 
becomes  permanent  and  may  be  heard  at  a  distance.  The  re- 
traction (tirage)  is  no  longer  interrupted,  and  manifests  itself 
above  as  well  as  below  the  sternum.  The  respiration  is  accel- 
erated, ranging  from  20  to  40  in  the  minute;  in  one  case  I  have 
seen  it '56.  The  patient  endeavors  to  compensate  for  the  in- 
sufficiency of  the  fullness  by  multiplying  the  number  of  in- 
spirations. If  the  respiration  rises  still  higher  we  have  to  fear 
inflammatory  complication  on  the  part  of  the  lungs.  With  the 
increase  of  restlessness,  the  distress  becomes  indescribable. 
On  applying  the  ear  to  the  chest  the  vesicular  murmur  is  no 
longer  heard  ;  it  hears  only  the  reverberation  of  the  laryngeal 
sound,  or  the  snoring,  or  rales  of  different  kinds  which  indicc  to 
the  extension  of  false  membrane  to  the  bronchi.  The  face  is 
purple  and  turgid ;  the  eyes  are  brilliant,  restless  and  imploring. 
The  patient  is  a  prey  of  constant  agitation,  and  cannot   remain 


208  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

quiet.  Surrounded  by  these  conditions,  death  may  occur  dur- 
ing a  paroxysm  of  suffocation.  But  in  the  ordinary  course  of 
the  disease,  whether  the  powers  become  exhausted,  or  the  ob- 
stacle becomes  insurmountable,  the  struggle  ceases,  the  par- 
oxysms of  suffocation  disappear,  the  patient  falls  again  upon 
his  bed  in  a  kind  of  stupor,  and  in  a  profound  depression ;  the 
face  ceases  to  be  cyanosed  and  swollen ;  it  becomes  pale,  al- 
though the  lips  as  well  as  the  skin  under  the  nails  remain 
purple ;  the  pulse  becomes  small,  insensible  ;  the  extremities 
become  cold  ;  anaesthesia  reaches  a  degree  almost  complete ; 
and  the  patient  expires  in  collapse. 

This  picture  represents  the  aspect  of  the  disease  in  cases  in 
which  its  development  is  natural,  in  those  in  which  the  laryn- 
geal obstruction  is  the  dominant  morbid  phenomenon,  when 
there  is  no  complication  and  when  the  diphtheritic  infection  is 
not  too  strongly  pronounced.  If  these  conditions  be  changed 
the  scene  changes  also. 

When,  for  example,  during  an  attack  of  coughing,  or 
during  an  effort  of  vomiting,  the  laryngeal  false  membrane  be- 
comes expelled  a  sudden  relief  of  the  symptoms  is  obtained, 
the  asphyxia  ceases,  wheezing  disappears,  respiration  becomes 
calm,  and  the  patient  falls  asleep  or  returns  to  his  play.  But 
it  is  too  often  only  a  respite.  The  diphtheria  is  always  there, 
master  of  the  situation.  The  expelled  false  membrane  is  fol- 
lowed by  another  exudation  which  in  the  course  of  a  longer 
or  shorter  time,  varying  from  four  to  twenty-four  hours,  is  in 
condition  to  present  a  new  obstacle.  The  scene  recommences, 
only  more  terrible,  the  patient  being  weakened  by  the  pre- 
ceding attack.  Three  or  four  repetitions  may  follow,  then 
comes  death. 

Nevertheless,  the  termination  may  be  more  fortunate,  the 
false  membrane  is  finally  detached  without  being  reproduced, 
or  after  being  removed  once  or  twice.  The  ameliortion  which 
results  from  it  is  followed  by  recovery.  While  this  change  in 
the  course  of  the  disease  is  quite  unusual,  it  is  less  rare  than 
Trousseau  supposed.  "There  are,  I  repeat"  says  the  illustrious 
professor,  "exceptional  cases,  so  rare  that  in  the  course  of  a  long 


LOCALIZATION  OF    DIPHTHERIA.  2O9 

medical  practice  in  which  it  has  been  my  province  to  see  a 
large  number  of  patients,  adults  as  well  as  children,  attacked 
with  croup,  I  have  met  only  six  of  them."  In  2809  cases  of 
croup  I  have  known  204  to  terminate  by  spontaneous  recovery 
due  to  the  expulsion  of  the  false  membranes.  That  is  to  say 
in  the  proportion  (average)  of  one  to  thirteen. 

Thus  far  I  have  insisted  upon  the  most  prominent  phenom- 
enon of  croup  viz.,  the  dyspnoea.  Around  that  gravitate  other 
symptoms. 

The  adenitis  depends  upon  the  form  of  the  diphtheria.  In 
the  benign  form  it  is  slight  or  absent,  in  the  malignant  form  it 
becomes  voluminous.  When  the  larynx  is  attacked  primarily 
it    is  wanting. 

The  fever  is  with  difficulty  appreciated  in  croup.  As  long 
as  the  disease  is  still  in  the  beginning,  the  pulse,  the  respira- 
tion and  the  temperature  allow  an  estimate  of  the  intensity  of 
the  fever.  At  this  time  the  febrile  movement  is  ordinarily 
moderate ;  the  pulse  remains  in  the  neighborhood  of  120  in 
the  minute ;  the  temperature  is  about  38.5°  (10172°  F.).  But 
when  the  respiration  is  embarrassed,  a  complete  disturbance 
prevails  over  these  functions.  The  anguish  and  the  excitement 
of  the  patient  cause  rapidity  of  the  pulse  and  make  it  irregu- 
lar. The  respiration  is  altered  in  its  rhythm  ;  it  is  at  one  time 
accelerated,  at  another  retarded  or  interrupted.  It  is,  there- 
fore, impossible  to  find,  from  this  source,  very  exact  notions 
concerning  the  fever.  The  temperature  itself  undergoes  mod- 
ifications, it  no  longer  expresses  the  variations  of  organic  com- 
bustion under  the  influence  of  the  diphtheritic  poisoning,  but 
the  disturbances  of  calorification  produced  by  asphyxia.  It  is 
not,  therefore,  to  speak  accurately,  the  febrile  condition  that 
can  be  determined,  but  only  one  of  its  elements — the  tracing 
of  the  temperature. 

From  the  commencement  of  asphyxia,  the  temperature  rises. 
I  have  never  insisted  on  taking  the  temperature  during  a  fit  of 
suffocation,  because  of  the  extreme  restlessness  of  the  patient; 
one  could  not  without  cruelty,  add  an  additional  restraint  to 
that  which  is  so  painfully  imposed.     Probably  there  is  a  rise  in 


2IO  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

the  temperature  corresponding  to  each  paroxysm.  In  con- 
tinued dyspnoea  the  only  condition  favoring  the  examination, 
the  themometer  marks  from  39°  to  40°  (102°  to  104°  F.). 
While,  if  by  the  expulsion  of  the  false  membrane,  or  from  the 
effects  of  tracheotomy  the  air  enters  the  chest  freely,  the  tem- 
perature falls  and  returns  to  its  point  of  departure;  it  rises 
again  if  the  reproduction  of  false  membranes  or  their  extension 
to  the  trachea  or  bronchi,  causes  a  return  of  the  asphyxia. 
Nevertheless,  the  rise  of  the  temperature  is  only  transient. 
Continuation  of  the  asphyxia  causes  a  final  decline  of  thermic 
range  and  death  follows  a  coldness  marked  by  36°  (97°  F.)  or  less. 

Before  reaching  this  fatal  issue,  the  coldness  may  also  be 
terminated  by  the  expulsion  of  a  false  membrane  or  by  tra- 
cheotomy. The  entrance  of  air  causes  the  thermometer  to  rise. 
These  apparently  contradictory  results  are  clearly  explained  by 
Claude  Bernard. 

In  a  dog  in  which  the  respiration  has  been  obstructed  by 
compressing  and  closing  the  nostrils,  the  temperature  was 
seen  to  rise,  and  to  become  normal  again  when  the  compres- 
sion was  removed.  But  if  the  asphyxia  was  maintained,  the 
temperature  finally  sank.  Brown-Sequard  obtained  similar  re- 
sults upon  birds.  From  these  facts  the  latter  observer  con- 
cluded that  asphyxia  from  deprivation  of  air  caused  a  tempo 
rary  elevation  of  animal  temperature. 

The  interpretation  of  the  phenomenon  would  be  the  follow- 
ing; if  the  oxygen  is  no  longer  supplied  from  without,  we 
must  not  conclude  that  it  is  entirely  wanting ;  the  arterial  and 
the  venous  blood  still  contains  a  large  proportion.  During 
asphyxia  this  oxygen  is  consumed  and  disappears  entirely.  At 
the  beginning  of  the  period  of  asphyxia  the  pulsations  of  the 
heart  become  less  rapid,  the  course  of  the  blood  is  slower,  this 
fluid  remains  longer  in  contact  with  the  intimate  structure  of 
the  tissues.  It  is  in  these  parts,  and  especially  in  the  muscular 
system  that  oxygen  completes  its  combustion.  The  excite- 
ment which  marks  the  beginning  of  asphyxia  and  the  convul- 
sive movements  which  sometimes  accompany  it,  are  important 
sources  of  heat  which   hasten   the   exhaustion   of   the  reserve 


LOCALIZATION  OF    DIPHTHERIA.  211 

oxygen.  Hence  the  increase  of  calorification  in  the  earl\-  part 
of  asphyxia.  But  when  the  supply  is  exhausted,  all  combus- 
tion   becomes    impossible    and    the    temperature    final!)-  falls.- 

One  can  understand  how,  in  asphyxia  at  the  beginning,  the 
return  of  air  into  the  chest  causes  the  temperature  to  fall 
by  diminishing  muscular  action  and  the  nervous  phenomena. 
While  in  prolonged  asphyxia  the  resumption  of  respira- 
tion causes  the  temperature  to  rise  by  supplying  a  new  food  to 
the  organic  combustion.  It  is  in  this  manner  that  the  rejec- 
tion of  false  membranes  and  tracheotomy  are  causes  of  a  re- 
turn of  the  thermic  tracing  (temperature  curve)  towards  the 
point  of  departure. 

After  the  expulsion  of  a  false  membrane  the  reproduction  of 
the  exudate  brings  new  variations;  after  tracheotomy,  the  ex- 
tension of  diphtheria  to  the  bronchi,  pulmonary  complica- 
tions, adenitis  and  even  the  removal  of  the  tube,  act  in  the 
same  way. 

The  expectoration  is  the  most  certain  source  of  valuable  in- 
dications in  respect  of  diagnosis,  prognosis  and  treatment.  At 
first  it  is  mucous  and  colorless,  but  it  ceases  at  the  moment  of 
clearly  defined  inflammation.  Finally  at  a  later  period  it  con- 
sists of  fragments  of  false  membrane  of  various  forms,  sizes  and 
composition.  Those  coming  from  the  larynx  are  irregular 
plates,  with  ragged  edges,  without  special  form,  sometimes  they 
have  nearly  the  form  of  a  trumpet,  when  they  come  from  the 
ventricles  of  the  larynx,  they  sometimes  retain  the  form  of  the 
vocal  cords.  At  others,  when  expelled  from  the  trachea  they 
consist  of  long  patches  the  surface  of  which  represents  portions 
of  the  surface  of  a  cylinder;  and  often  one  extremity  of  the 
plate  represents  quite  clearly  the  bifurcation  of  the  trachea. 
The  bronchi  furnish  their  share  also  of  the  expectoration  ;  the 
false  membranes  which  come  from  them  are  occasionally  quite 
considerable ;  they  give  an  exact  form  of  the  part  on  whieh 
they  are  formed.     See  pathological  anat.  p. — 

The  expectoration,  while  containing    the    false    membranes 
contains  also  mucus,  often  sanguinolent,   or    even    a    sero-san- 
guinolent  or  sero  purulent  material,  sometimes  very  abundant. 


212  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

Later,  when  the  course  is  favorable,  the  material  becomes 
simply  mucous. 

The  odor  of  the  expectoration  varies  with  the  general  con- 
dition; negative  in  the  benign  form,  it  becomes  gangrenous  in 
the  infectious  and  malignant  forms.  When  a  thoracic  inflam- 
mation develops  itself,  the  expectoration  ceases  for  the  time, 
only  to  return  at  the  time  of  resolution. 

When  the  expelled  false  membrane  is  thin  and  soft,  it  very 
much  resembles  mucus.  To  avoid  all  confusion,  it  is  well  to 
stir  the  expectorated  material  in  a  glass  of  water.  Under  these 
conditions  the  false  membrane  rolls  out  and  resumes  its  form, 
color  and  opacity,  while  the  mucus  spreads  out  and  remains 
transparent.  Still  other  symptoms  are  met  with  in  croup  but 
they  have  nothing  that  connects  them  directly  with  this  locali- 
zation; they  are  common  to  all  the  forms  of  diphtheria.  They 
are : 

Anorexia,  which  is  often  absolute,  and  becomes  one  of  the 
most  serious  of  the  perils  which  threaten  the  patient.  The 
combination  of  inanition,  infection,  and  asphyxia  leaves  no 
chance  for  recovery. 

Constipation,  and  occasionally  diarrhoea  which,  independ- 
ently of  cases  in  which  it  follows  the  use  of  emetics,  may  be 
encountered  in  the  beginning,  or  in  the  course  of  the  disease. 
In  the  forms  in  which  infection  prevails,  the  diarrhoea  may  be 
fetid  as  well  as  the  other  secretions. 

Vomiting,  quite  frequent  at  the  outset,  appears  occasionally 
in  the  course  of  the  disease,  most  frequently  at  the  approach 
of  a  complication.  Often  also  it  is,  as  in  the  case  of  diarrhoea, 
the  consequence  of  the  treatment  by  emetics;  occasionally 
this  treatment  produces  a  similar  effect  only  after  tracheotomy. 
Haemorrhages  occur  from  various  points,  especially  from  the 
nose,  mouth,  cutaneous  ulcerations,  or  from  the  wound  of 
tracheotomy ;  sometimes  at  the  beginning,  sometimes  in  the 
course  of  the  disease.  It  is  reckoned  among  the  gravest 
symptoms. 

Albuminuria  is  so  frequent  in  croup  that  some  authors  have 
considered  it  as  dependent  upon  the  asphyxia;  it  has  been 
found  that  there  is  nothing  in  that  view. 


LOCALIZATION    OF     DIPHTHERIA,  213 

Finally,  scarlatiniform  or  rubeoliform  eruptions  are  met  with 
under  some  circumstances. 

PATHOLOGICAL    PHYSIOLOGY. 

The  anatomical  lesions  generally  comprise  the  symptoms 
observed  in  patients  attacked  with  croup.  Like  all  rules,  this 
has  exceptions.  When  we  find,  after  death,  wide  fibrinous  cyl- 
inders lining  the  respiratory  mucous  membrane,  or  simply 
thick  concretions  attached  either  to  the  lips  of  the  glottis  or  to 
the  margins  of  the  aryteno-epiglottic  ligaments,  the  dyspnoea 
and  asphyxia  find  their  explanation :  the  relation  is  established 
between  the  lesions  and  the  symptoms.  But  when  these  parts 
are  simply  covered  with  a  thin  pseudo-membranous  coating, 
when  we  find  at  the  autopsy  only  trifling  exudations  or  even 
none,  and  yet  the  respirator}'  disturbance  has  been  most  vio- 
lent, then  the  connection  is  severed. 

The  intermittent  dyspnoea  and  the  paroxysms  of  suffocation 
present  also  difficulties  for  explanation.  Many  times  these 
paroxysms  cease  after  the  expulsion  of  a  false  membrane,  but 
in  numerous  cases  it  is  otherwise.  Hence  we  find  ourselves 
at  one  time  dealing  with  an  intermittent  phenomenon  which 
appears  to  depend  upon  a  structural  lesion — the  false  mem- 
brane ;  at  another  with  violent  disturbances  coincident  with 
anatomical  alterations  quite  insignificant  in  appearance.  This 
want  of  correspondence  has  engaged  the  attention  of  all  au- 
thors. Jurvie,  Vieusseux,  Albers  of  Bremen,  Royer-Collard 
and  Double  have  attributed  it  to  a  spasm  of  the  glottis,  the 
origin  of  which  may  be  inflammation  of  the  respiratory  mu- 
cous membrane.  In  the  view  of  these  authors  the  false  mem- 
brane plays  a  subordinate  role  in  the  embarrassment  of  the 
respiration,  the  spasm  alone  preventing  the  entrance  of  air 
into  the  chest.  Bretonneau  held  an  opposite  opinion.  The 
false  membrane  is  the  special  agent  in  the  suffocation.  We 
may  not,  without  error,  regard  the  intermittence  as  a  purely 
nervous  or  spasmodic  phenomenon  ;  it  is  met  with  under  many 
circumstances,  viz.,  in  cancer,  in  calculous  affections,  etc. 

This  interpretation  was  fully  admitted  by  Valleix,  but  only 


214  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

partly  by  Trousseau,  and  is  no  longer  accepted.  Barthez  and 
Rilliet,  Lallemand  and  Simon  ascribe  the  principal  part  to  the 
spasmodic  element. 

Other  authors,  relying  upon  the  lesions  of  nutrition  found  in 
the  muscles  of  the  larynx,  by  virtue  of  the  law  of  Stokes,  that 
is,  upon  the  propagation  of  the  inflammation  to  the  muscles 
beneath  the  mucous  membrane,  have  located  the  laryngeal  dif- 
ficulties in  the  muscular  paralysis  resulting  from  this  anatomical 
condition.  The  opinion  of  Bretonneau  cannot  be  accepted  in 
the  present  state  of  science.  However  real  and  however 
potent  may  be  the  obstructive  action  of  the  false  membrane, 
there  exist  too  many  cases,  in  which  an  intense  respirator^'  dis- 
turbance coincides  with  a  false  membrane  trifling  in  thickness 
and  extent,  for  us  not  to  seek  another  cause  of  dyspnoea. 

Let  us  consider  first  the  paroxysm  of  suffocation ;  it  is  near 
the  beginning  that  it  occurs,  while  it  ceases  or  becomes  more 
rare  as  the  disease  becomes  more  advanced,  and  as  the  exuda- 
tion increases  in  thickness.  Besides,  lar}'ngitis  stridulosa  pre- 
sents symptoms  in  every  respect  similar,  viz.,  paroxysms  of 
suffocation  and  of  laryngo-tracheal  wheezing  without  it  being 
possible  to  attribute  it  to  a  false  membrane  or  to  a  sufficient 
mechanical  obstacle.  Now  a  simple  tumefaction  of  the  mu- 
cous membrane  would  but  seldom  produce  symptoms  equally 
serious;  oedema  of  the  glottis  alone  might  produce  a  suf- 
ficiently swelled  condition  of  the  parts.  Whooping  cough 
itself,  during  the  paroxysm,  gives  rise  to  a  similar  wheezing. 
The  presence  of  false  membrane  is  not,  therefore,  indispensable 
in  provoking  an  attack  of  suffocation. 

By  what  mechanism  can  the  larynx  contract  to  a  degree 
sufficient  to  produce  suffocation  without  the  co-operation  of 
exudation? 

The  laryngeal  muscles  alone  are  endowed  with  that  power. 
Do  they  act  by  paralysis  or  by  spasmodic  contraction  ?  Paral- 
ysis, based  upon  the  alteration  of  the  muscles,  does  not  ap- 
pear to  me  satisfactory  so  far  as  the  attacks  of  suffocation  are 
concerned  ;  from  that  condition  arises  dyspnoea,  not  intermit- 
tent, but  permanent,  which,  by  the   expulsion   of  false  mem- 


LOCALIZATION     OF    DIPHTHERIA.  21 5 

branes,  would  not  be  even  changed.  Periodicity  is  rarely 
found  among  the  paralytic  phenomena.  Moreover,  at  the  time 
when  the  paroxysms  of  suffocation  appear  there  is  nothing  to 
prove  that  the  muscular  lesions  are  sufficiently  advanced  to  de- 
stroy the  function  of  these  organs. 

Spasm,  therefore,  remains  to  be  considered ;  this  is  probably 
the  most  active  agent  in  the  laryngeal  occlusion.  As  in  stridu- 
lous  laryngitis  and  in  whooping  cough,  it  is  under  the  influ- 
ence of  irritation  of  the  mucous  membrane.  The  laryngeal 
mucous  membrane  in  the  child  is  exquisitely  sensitive;  the 
slightest  inflammation  easily  assumes  the  spasmodic  form. 
Everv  irritant,  even  inspired  air,  is  to  the  inflamed  membrane 
a  causi  of  hyperaesthesia  which,  transmitted  to  the  medulla  by 
the  superior  laryngeal  branch  of  the  pneumogastric  and  re- 
tlccicd  by  the  inferior  or  recurrent  laryngeal  to  the  muscles  of 
the  Larynx,  excites  the  contraction  of  those  muscles.  Now,  as 
these  are  all  constrictors  of  the  glottis  except  the  posterior 
crico-arytenoid  muscles,  their  contraction  produces  a  degree  of 
constriction  of  the  glottis  in  proportion  to  the  activity  of  the 
irritant.  When  this  agent  is  inspired  air,  of  which  the  action 
is  continuous,  the  occlusion  itself  is  continuous  and  moderate; 
it  is  announced  by  the  laryngo-tracheal  wheezing.  But  let 
this  hyperaesthesia  be  suddenly  increased  by  another  im- 
pression, and  the  mucous  membrane  reacts  violently.  A  sud- 
den and  violent  constriction  of  the  glottis  results  therefrom, 
which,  being  added  to  the  stenosis  dependent  upon  the  false 
membrane,  closes  the  air-passage ;  hence  the  suffocation. 
Causes  trifling  in  appearance  are  sufficient,  such  as  an  emo- 
tion, fright,  anger,  a  movement,  or  the  displacement  of  the 
false  membrane.  When  the  reaction  ceases  the  muscular  con- 
traction relaxes,  the  attack  terminates  and  the  hyperaesthesia 
of  the  mucous  membrane  returns  to  its  condition  before  the 
paroxysm.  Fiequcntly  it  remains  more  marked,  a  condition 
which  explains  the  greater  intensity  of  the  wheezing  after  the 
paroxysm  of  suffocation. 

In  the   adult,   diminished   irritability  of  the   mucous  mem- 
brane, the  greater  dimensions  of  the   larynx  and  the  existence . 


2l6  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

of  the  aryteno-glottic  render  the  effect  of  the  spasm  less  evi- 
dent;  besides,  the  attacks  are  more  rare,  and  they  announce 
the  more  direct  interference  of  the  false  membrane. 

Such  is  in  part  the  mechanism  of  a  paroxysm  of  suffocation. 
I  can  scarcely  believe  that  it  is  always  so  simple.  There  are 
too  many  causes  of  occlusion  of  the  glottis  present  to  suppose 
that  they  would  not,  by  combining,  produce  phenomena  more 
complex.  To  the  reflex  contraction,  arising  from  inflamma- 
tion of  the  mucous  membrane,  is  added  that  which  results  from 
the  extension  of  the  inflammator}'  action  to  the  muscular  tissue 
itself.  Under  these  conditions  the  muscles  react  as  does,  for 
example,  the  anal  sphincter  in  dysentery,  in  such  a  manner  as 
to  cause  a  kind  of  glottic  tenesmus  which  acts  in  the  same 
way  as  the  reflex  spasmodic  action.  This  hypothesis  once  ad- 
mitted, the  suffocative  attacks  may  therefore  be  the  product  of 
three  factors  of  which  the  importance  varies  according  to  the 
case:  i.  False  membrane.  2.  Reflex  contraction  of  the  laryn- 
geal muscles  from  irritation  of  the  mucous  membrane.  3.  Te- 
nesmus glottidis  caused  by  the  extension  of  mucous  inflamma- 
tion to  the  muscular  tissue  itself. 

At  a  later  period  the  paroxysms  disappear,  and  the  dyspnoea 
becomes  continuous.  Rarely  does  the  false  membrane  become 
so  thick  and  so  extended  as  to  entirely  intercept  the  access  of 
air.  It  is  then  that  muscular  paralysis  intervenes.  The  laryn- 
geal muscles  no  longer  contract,  first,  because  the  mucous 
membrane,  having  lost  its  sensibility,  no  longer  reacts,  and 
then,  because  they  are  altered  and  become  fatty,  as  a  number 
of  autopsies  have  proved ;  their  contractile  elements,  which 
remain  healthy,  are  in  too  small  a  number.  The  larynx  is 
found  then  in  a  condition  analogous  to  that  which  follows  sec- 
tion of  the  superior  and  inferior  laryngeal  nerves,  viz.,  sup- 
pression of  sensibility  and  abolition  of  motion,  hence  asphyxia. 

COURSE. 

I  have  confined  myself  to  signalizing  the  variations  of  the 
onset.  Bretonneau  represented  croup  as  always  being  pre- 
ceded by  coryza  or  diphtheritic  angina,  but  it  may  suddenly 
appear   primarily,  and    even  be  followed  by  angina.     When 


LOCALIZATION     OF     DIPHTAERIA.  21/ 

it  appears  primarily  and  when  it  follows  angina,  coryza, 
or  bronchitis,  it  begins  by  characteristic  alterations  of  the 
cough,  the  voice  and  the  respiration,  which  constitute  the  first 
period.  The  time  occupied  by  the  beginning  of  the  angina 
appears  to  vary  with  the  epidemics.  In  those  which  Breton- 
neau  observed  this  period  continued  from  two  to  seven  days ; 
in  that  epidemic  which  passed  under  the  observation  of  Fer- 
rand  it  lasted  but  a  single  day.  In  232  cases  of  croup  in 
which  the  disease  has  been  followed  from  its  beginning,  I 
have  seen  the  larynx  attack : 

At  the  same  time  as  the  throat,         -         -         -  1 1  times 

Some  hours  after,  ___--.  6  times 

DAYS    AFTER.  TIMES.  DAYS    AFIER,  TIMES. 

I         -         -         -  29  8          -         -         -  13 

2---  33  9---  2 

3  -         -         -  46  10         -         -         -  5 

4  -         -         -  33  II         -         -         .  I 
5---  26  12---  I 

6  -        -        -         17  15         -        -        _  2     . 

7  -  -  -  6  27---  I 


Total.  _____  232 

These  figures  result,  in  large  part,  from  information  furnished 
by  the  parents  of  the  children.  They  can  only  be  received 
with  reserve.  Among  the  patients  who  come  to  hospitals  many 
are  attacked  with  diphtheritic  angina  unnoticed ;  the  attention 
of  parents  is  attracted  only  when  the  laryngeal  symptoms  ap- 
pear; it  is  often  difficult  to  fix  the  date  of  the  extension  of  the 
false  membrane  from  the  pharynx  to  the  larynx.  In  making 
allowance  for  these  unavoidable  errors,  we  should,  however, 
recognize  the  important  grouping  of  the  most  numerous  cases 
about  the  first  seven  days. 

Croup,  when  once  established,  runs  a  variable  course,  i.  It 
runs  through  the  three  periods  and  ends  in  asphyxia,  when  it 
is  abandoned  to  itself;  2.  A  violent  attack  of  suffocation  closes 
the  scene ;  3.  the  expulsion  of  a  false  membrane  gives  tempo- 
rary relief  or  cures  the  patient;  4.  tracheotomy  intervenes  and 
permits  the  diphtheria  to  follow  its  course  by  relieving  the  ele- 
ment of  asphyxia;   5.  numerous  complications,    viz:    eruptive 


2l8  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

fevers,  thoracic  or  other  lesions  impeding  the  course  of  the 
croup  when  the  operation  has  been  performed,  and  when  not. 
Under  these  different  circumstances  the  form  of  the  diphtheria 
frequently  changes,  as  also  does  the  physiognomy  of  the  dis- 
ease. 

The  infectious  form,  in  which  are  classed  many  of  the  cases 
of  secondary  croup,  is  characterized  by  the  rapidity  of  the  in- 
vasion, by  the  extension  of  the  false  membranes  to  the  bron- 
chial tubes,  or  by  the  gravity  of  the  symptoms  of  infection. 
Should  the  larynx  be  attacked  primarily  or  after  the  throat,  the 
development  may  be  very  rapid.  Instead  of  some  days,  a  few 
hours  may  suffice  to  overstep  the  space  which  separates  these 
two  regions ;  sometimes  they  are  attacked  at  the  same  time. 
The  process  develops  itself  with  a  kind  of  precipitation.  One 
day,  a  day  and  a  half  or  two  days  are  sufficient  to  reach  the 
development;  and  a  severe  attack  of  suffocation,  sometimes  re- 
peated, is  the  first  symptom,  immediately  followed  by  continued 
dyspnoea.  It  is  for  this  variety  that  the  name  fiilnii?ia)it  form 
of  croup  (croup  foudroyant)  is  reserved.  In  other  cases  it  is  the 
second  period  which  fails;  the  continued  dyspnoea  is  estab- 
lished without  paroxysms  of  suffocation.  This  is  principally 
observed  when  the  false  membrane  descends  into  the  bronchi. 
We  do  not  then  observe  the  violent  struggles  of  the  patient 
against  asphyxia.  There  are  no  longer  the  restlessness,  the 
turgescence  of  the  face  and  the  cyanosis,  but  there  are  prostra- 
tion, drowsiness,  pallor  and  failure  of  the  powers.  Ramified 
false  membranes  are  often  expelled. 

If  the  croup  depends  on  malignant  diphtlieria,the  spread  of  the  false  membrane  is 
rapid — the  blow  is  sudden,  the  paroxysms  of  suffocation  most  frequently  fail,  and  as- 
phyxia is  progressive.  The  following  is  a  striking  example  of  precipitation  in  the 
course:  In  a  patient  attacked  with  measles,  on  the  morning  of  the  fifth  day  of 
the  eruption,  inflammation  of  the  sub-maxillary  glands,  larj'ngo-tracheal  wheezing^ 
and  obscurity  of  the  vesicular  murmur  were  observed;  the  throat  presented  only  a 
little  redness.  In  the  evening  there  was  the  same  laryngeal  cough  and  with  it  expul- 
sion of  a  tubulated  false  membrane  coming  from  the  trachea,  three  centimeters  (more 
than  an  inch)  in  length.  The  next  day  false  membranes  were  on  the  tonsils,  there  Was 
increase  of  the  dyspnoea  of  the  continued  type,  and  death  followed  in  the  night.  The 
post-mortem  examination  revealed  false  membranes  as  far  as  the  small  bronchioles. 
All  this  occurred  in  two  days. 


LOCALIZATION    OF    DIPHTHERIA,  219 

But  frequently  the  asphyxia  is  no  longer,  as  in  the  preced- 
ing forms,  the  prominent  phenomenon;  infection  holds  the  first 
rank.  The  patient  having  to  contend  at  once  against  defective 
haematosis  and  the  profound  toxic  effects,  and  haemorrhages, 
diarrhoea,  adenitis,  etc.,  soon  sinks. 

Age  also  makes  its  impress  upon  the  symptomatic  totality. 
The  condition  which  I  have  described  belongs  to  the  croup  of 
children.  That  of  adults  takes  a  somewhat  different  course. 
The  character  of  the  cough  and  voice  are  the  same,  the  aphonia 
occurs  quite  rapidly.  But  the  dyspnoea  comes  on  more  slowly, 
the  lar>'ngo-tracheal  wheezing  often  fails,  as  well  as  the  par- 
oxysms of  soffocation ;  the  dyspnoea  assumes  the  continued 
form  and  the  the  asphyxia  becomes  gradually  established  ; 
when  paroxysms  do  exist  they  are  of  great  violence,  and  the 
patient  may  expire  during  one  of  them.  Aside  from  some  of 
these  peculiarities  the  disease  follows  the  same  course  as  in  the 
child. 

The  course  of  croup  is  continued  and  progressive ;  the  ac- 
cessions of  suffocation,  which  impress  upon  it  a  kind  of  shock 
or  paroxysm  more  or  less  violent,  are  followed  by  increase  of 
the  dyspnoea.  Each  paroxysm  is  nearly  always  more  power- 
ful than  the  preceeding ;  the  respiratory  restraint  which  sep- 
arates it  from  the  future  paroxysm  is  more  intense  than  that 
which  separated  it  from  the  previous  one.  These  are  the  de- 
grees by  which  the  disease  rises  progressively  to  asphyxia. 

Remissions,  generally  due  to  expulsion  of  false  membranes, 
sometimes  slacken  the  course  of  the  disease,  and  even  make 
it  change  front  altogether,  but  they  are  rare  and  nearly  always 
followed  by  an  aggravation  which  gives  to  the  progressive 
course  a  fresh  impulse.  Jaccoiid  describes  an  intermittent 
form  of  croup  characterized  by  complete  remissions  which  ap- 
pear in  the  morning  and  may  be  prolonged  until  evening. 
Then  the  dyspnoea  and  paroxysms  return.  These  alternations 
may  be  repeated  for  several  days  and  thus  give  to  the  disease 
an  appearance  of  intermittence.  Often  in  the  morning  we  ob- 
serve a  certain  remission  of  the  symptoms  ;  but  I  have  never, 
for  my  part,  met  with  a  true  intermittence. 


220  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

In  some  very  rare  cases  we  may  observe  a  cessation  in  the 
progress  of  the  disease. 

A  palient,  set  l8  months,  attacked  with  croup,  presented  three  remissions,  on  the 
third,  the  ninth  and  the  twelfth  day ;  the  first  lasted  one  day,  the  second  two  days  and 
the  third  five  days;  the  last  relapse  took  placeon  the  seventeenth  day.  During  these 
periods  of  quiet  the  respiration  became  almost  completely  free,  there  remained  but  a 
slight  roughness  of  ihe  voice  and  cough.  A  fact  still  more  remarkable  was  that  the 
first  relapse  was  marked  by  paroxysms  of  suffocation,  which  did  not  characterize  the 
other  relapses,  at  least  up  to  the  seventeenth  day  at  which  time  the  child  was  taken 
from  the  hospital  by  his  parents.  In  another,  aet  2  years,  attacked  also  with  croup, 
passed  also  to  the  second  period,  with  paryoxsms  of  suffocation,  a  remission  mani- 
fested itself  the  fourth  day  and  continued  four  days,  during  which  the  res- 
piration was  free  and  noiseless.  The  relapse  which  followed  gave  rise  to  attacks  ot 
suffocation,  but  it  ended  in  recovery  at  the  end  of  eight  days,  and  by  paralysis  of  the 
soft  palate  and  the  larynx.     In  both  cases  there  was  diphtheritic  angina. 

TERMINATION. 

Left  to  itself  the  natural  tendency  of  croup  is  to  asphyxia 
and  death.  Recovery  is  rare.  In  2,809  cases  of  croup  204, 
that  is  one  in  about  thirteen,  were  able  to  recover  without  re 
quiring  surgical  aid,  275  died  in  which  tracheotomy  could  not 
be  performed.  Of  the  remainder,  2,312  had  to  seek  relief  from 
asphyxia  by  the  tracheal  incision.  Recovery  may  be  reached 
in  cases  in  which,  the  diphtheria  being  benign,  the  false  mem- 
brane thin,  narrow,  and  the  spasm  moderate,  the  laryngeal  ob- 
stacle is  capable  of  producing  respiratory  disturbances  of  the 
first  and  even  of  the  second  period,  but  is  not  sufficient  to  com- 
pletely intercept  the  passage  of  air  or  to  produce  asphyxia. 
Croup  ceases  in  the  first  or  in  the  second  period.  The  false 
membrane  separates  as  in  benign  diphtheria,  and  recovery  takes 
place. 

If  the  process  is  more  active  the  symptoms  are  more  grave, 
and  the  tendency  to  asphyxia  is  more  marked.  A  chance  of  re- 
covery still  remains,  viz  :  the  expulsion  of  the  obstructing  false 
membrane  by  the  effort  of  coughing  or  vomiting.  While  too  often 
transient,  the  benefit  obtained  by  removing  the  obstruction  from 
the  larynx  may  become  final  from  the  first  time,  or  only  after 
several  alternations  of  alleviation  and  return  of  these  symp- 
toms. 

Asphyxia  is  the  principal  cause  of  death.     Occlusion  of  the 


LOCALIZATION     OF     DIPHTHERIA.  221 

larynx  by  false  membrane  or  by  spasmodic  contraction,  fol- 
lowed by  paralysis  of  the  muscles  of  the  larynx,  is  generally 
the  mechanism  by  which  it  is  accomplished.  Other  causes 
may  hasten  the  effects  of  it  or  add  fatal  consequences  to  these 
obstacles,  which,  so  far  as  the  structure  is  concerned,  might 
be  incapable  of  causing  death.  The  propagation  of  false  mem- 
branes to  the  trachea  and  to  the  bronchi  is  the  most  common 
and  the  most  rapid  method.  The  small  quantity  of  air  which 
passes  the  larynx  finds  no  longer  sufficient  surface  for  the 
necessary  exchange  between  the  blood  and  the  external  air. 
The  defective  oxygenation,  and,  as  a  consequence,  death,  are 
inevitable,  should  bronchitis  be  somewhat  extensive.  All  the 
thoracic  complications,  such  as  bronchitis,  broncho-pneumonia, 
pneumonia,  pleuritis,  etc.,  act  in  the  same  way.  Extensive  poi- 
soning of  the  system  is  added  to  the  respiratory  impediment  in 
producing  death.  The  mechanical  obstruction  is  surpassed  by 
the  poisoning  which  conduces  to  the  dreaded  result  in  the 
midst  of  ataxo-adynamic  phenomena  most  pronounced.  I 
have  seen  one  case  of  this  kind  terminate  fatally  in  less  than 
twenty-four  hours.  Inanition,  a  consequence  so  frequent  of 
the  repugnance  for  food,  which  characterizes  the  grave  forms 
of  diphtheria,  has  no  less  influence  upon  the  termination. 
Sudden  death  is  not  very  rare.  During  the  progressive  pe- 
riod it  is  nearly  always  due  to  laryngeal  asphyxia ;  the  patient 
sinks  during  a  paroxysm  of  suffocation.  In  one  case  death 
by  asphyxia  was  produced  in  a  few  moments  without  showing 
the  usual  appearance  of  paroxysms  of  suffocation.  The  au- 
topsy revealed  the  lower  part  of  the  trachea  filled  by  a  plug 
of  false  membranes  formed  by  a  patch  detached  from  the  su- 
perior part  and  rolled  upon  itself  Convulsions  are  some- 
times the  final  phenomena.  Sudden  death  by  syncope,  much 
more  rare,  is  observed  especially  during  convalescence,  at  a 
time  when  paralysis  prevails. 

DURATION. 

All  the  causes  which  modify  the  course  of  croup  and  influ- 
ence its  termination  produce  their  effects  upon  its  duration. 
Beyond  all  others,  tracheotomy  produces  considerable  changes 


222  DIl'HTHERIA,    CROUP    AND     JKACllKOTOMV. 

in  the  course  of  the  disease  or  upon  its  issue,  by  suppressing 
the  asphyxia,  postponing  death,  or  bringing  about  recovery. 
The  time  occupied  in  reaching  one  or  the  other  of  these  is- 
sues, when  croup  is  subjected  to  tracheotomy,  would  not  give 
the  real  duration  of  the  disease.  When  the  operation  is  per- 
formed, and  the  laryngeal  obstacle  obliterated,  croup,  with  its 
special  symptoms,  no  longer  exists,  it  is  reduced  to  a  diphthe- 
ria more  or  less  extended,  more  or  less  complicated. 

It  is  of  croup  without  the  operation  that  we  must  make  the 
necessary  inquiries.  Operated  croup  may,  however,  furnish 
very  useful  information.  The  operation  is  practiced,  in  the 
large  majority  of  cases,  at  least  in  those  which  have  come  un- 
der my  observation,  in  the  third  period,  at  the  time  of  as- 
phyxia; and  it  is  not  preventive,  but  palliative,  furnishing  a 
supply  of  air  to  the  unfortunate  patient  who  is  strangling. 
Excepting  the  cases  operated  on  in  extremis,  it  precedes,  by  a 
few  hours,  the  moment  when  the  patient  would  succumb  if  de- 
prived of  its  aid.  In  these  cases  the  period  comprised  be- 
tween the  beginning  and  the  time  of  tracheotomy  may,  there- 
fore, be  considered  as  representing  quite  approximately  the 
duration  of  croup  terminated  by  asphyxia.  By  consulting  the 
following  table  one  will  see  that  in  the  cases  of  croup  which 
died  abandoned  to  themselves,  as  in  those  which  were  arrested 
for  the  time  by  tracheotomy,  the  most  numerous  are  found  in 
the  first  three  days.  As  to  the  operated  cases  the  transition 
is  abrupt ;  from  the  third  to  the  fourth  day  the  figures  fall 
from  150  to  ninety;  on  the  following  day  the  descent  is  still 
more  considerable  ;  we  find  only  forty-four  cases.  It  is,  there- 
fore, evident  that  the  greatest  number  of  patients  succumb  to 
asphyxia  before  the  fifth  day. 

In  the  column  which  contains  the  cases  of  death  from  croup, 
left  to  themselves,  the  decrease  is  progressive  including  the 
fourth  day;  then  the  mortality  rises  suddenly  the  fifth  day, 
to  fall  again  the  sixth.  The  cases  of  this  class  appear,  there- 
fore, to  continue  longer  than  those  which  reach  tracheotomy. 
There  is  a  reason  for  this  difference.  We  operate  by  prefer- 
ence on  those  patients  in  whom  the  asphyxia  by  laryngeal  ob- 


LOCALIZATION    OF     DIPHTHERIA.  223 

struction  is  the  dominant  feature,  those  in  whom  the  poison- 
ing seems  sHght.  These  are  arrested  at  the  end  of  the  third 
or  fourth  day  at  farthest.  We  avoid,  as  far  as  possible,  op- 
erating on  those  in  whom  the  obstruction  is  not  Hmited  to  the 
larynx,  in  whom  the  diphtheria  is  general,  and  who  show 
signs  of  profound  poisoning.  If  in  these  cases  the  course  may 
be  rapid,  as  the  figures  show  for  the  first  three  days,  it  is  oth- 
erwise when  death  depends  much  less  upon  asphyxia  than 
upon  the  general  symptoms.  In  this  category  are  found  the 
patients  who  die  on  the  fifth  day  and  the  following  days: 


DURATION, 

Croup  not 

operatec 

on- 

Croup  operated  on. 

r 

N 

From  the  beginning  to 

Recovered. 

Died. 

the  operation. 

Number  of  the  day. 

Cases. 

Cases. 

Cases. 

I 

- 

10 

92 

2 

- 

18 

152 

3 

I 

13 

150 

4 

2 

10 

90 

5 

3 

15 

44 

6 

2 

5 

32 

7 

4 

3 

9 

8 

4 

5 

17 

9 

I 

2 

3 

10 

9 

5 

3 

II 

6 

3 

I 

12 

4 

I 

— 

13 

2 

— 

— 

14 

I 

— 

— 

15 

3 

— 

— 

16 

I 

— 

— 

17 

3 

— 

— 

18 

2 

— 

• — 

19 

3 

— 

— 

20 

I 

— 

— 

21 

I 

— 

— 

22 

3 

— 

— 

23 

I 

— 

— 

26 

2 

— 

— 

27 

I 

— 

— 

32 

I 

— 

— 

60 

I 

— 

— 

224  DIPHTHERIA,    CROUP  AND    TRACHEOTOMY. 

If  the  preceding  figures  give  exact  results  in  respect  of  croup 
terminating  in  death  or  in  tracheotomy,  it  is  not  equally  true 
for  the  cases  which  recover  spontaneously.  In  fact  it  is  diffi- 
cult to  fix  the  time  when  croup  ceases.  The  symptoms  of  this 
disease  being  the  peculiar  characteristics  of  the  cough  and 
voice  as  well  as  of  the  respiratory  impediment,  one  may 
consider  the  disease  as  terminated  only  when  all  these  disturb- 
ances have  disappeared.  Now,  alterations  of  the  voice  and  of 
the  cough  often  persist  for  a  long  time.  On  the  contrary,  by 
limiting  croup  to  the  single  presence  of  respiratory  restraint 
would  be  to  expose  ones  self  to  commit  serious  mistakes. 
Dyspnoea  may  cease  before  the  false  membranes  have  entirely 
disappeared,  and  we  have  no  rational  means  of  ascertaining 
this  disappearance  as  to  the  exact  moment.  Careful  examina- 
tion with  the  laryngoscope  could  alone  supply  the  exact  indi- 
cations. Another  element  of  information  more  exact  is  fur- 
nished by  the  expulsion  of  the  false  membranes.  If  after  the 
expulsion  of  one  or  several  fragments  of  pseudo-membranous 
debris,  the  respiratory  impediment  ceases  in  a  definite  man- 
ner, we  may  presume  that  the  last  expulsion  leaves  the  respi- 
ratory mucous  membrane  entirely  clean,  and  fix  that  date  as 
the  termination  of  the  croup.  Now,  the  expulsion  of  false 
membranes  seldom  extends  beyond  the  first  week ;  it  may  cease 
from  the  next  day  after  the  operation,  but  it  may  reach  the 
twenty-second  and  even  the  thirty-second  day,  as  I  have 
myself  witnessed.  These  latter  cases  are  exceptional;  they 
are  only  explicable  by  successive  exudations  of  false  mem- 
branes. It  is  necessary  to  consider  also,  the  concretions  which 
are  expelled  at  the  end  of  the  first  ten  or  twelve  days.  In  re- 
ality, while  in  the  tracheotomized  cases  which  recover  rapidly, 
the  false  membranes  cease  to  appear  at  the  end  of  ten  days, 
in  croup  not  operated  the  maxinum  of  recoveries  is  made  in 
the  first  eleven  days.  Moreover,  we  have  observed  that  the 
false  membranes  of  the  throat  which  are  held  more  tenaciously 
than  those  of  tthe  respiratory  passages,  separate  from  the  fifth 
to  the  fifteenth  day. 

It  is    useful    also  to  know  the  duration  of  tracheotomized 


LOCALIZATION    OF    DIPHTHERIA. 


225 


croup.  This  is  no  longer  the  duration  of  croup  in  which  only 
the  evolution  of  false  membrane  and  its  effects  are  considered, 
but  that  of  croup  in  its  complex  condition  in  which  it  appears 
most  frequently.  Under  these  conditions  croup  has  a  dura- 
tion, in  the  fatal  cases,  of  from  one  to  fifty-two  days ;  the 
greatest  mortality  manifested  itself  between  the  second  a^^d 
eighth  days.  In  those  in  which  the  issue  was  favorable  the 
duration  was  from  eight  to  126  days,  without  showing  any 
great  preference  for  any  one  period  in  particular.  The  most 
numerous  recoveries  definitely  were  on  the  fifteenth,  twentieth 
and  the  thirtieth  daj's, 

Th^e  elements  which  enable  one  to  determine  the  length  of 
the  periods  of  croup  are  more  rare.  Not  only  one  or  two  of 
them  may  be  wanting,  but  the  information  furnished  by  tiie 
attendants  is  very  indefinite.  For  the  second  and  the  third 
periods  especially,  the  results  fail  of  ^^recision.  By  rejecting 
the  doubtful  cases  I  have  arrived  at  the  conclusion  that  for  the 
first  period  the  duration  oscillates  most  frequently  between  one 
and  four  days;  and  that  it  seldom  exceeds  one  day  for  the 
second,  and  rarely  extends  beyond  a  few  hours  for  the  third. 

Duration. 

Days. 

I 
2 

3 
4 
5 
6 

7 
8 

9 
10 

SECOND  ATTACKS  (rECIDIVES.). 

Croup  may  attack  the  same  subject  at  several  different  times. 
Guersant,  Gombault,  Warmont  and  Millard  have  had  to  operate 


PERIODS  OF 

CROUP. 

Number  of  Cases. 



A 

First  period.     Second  period. 
Cases.                    Cases. 

Third  period. 

7 

Few  hours. 

45 
60 

I] 

« 
« 

32 
16 

7 
6 

it 

(C 

I 

(( 

I 

« 

I 

<i 

I 

(( 

226  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

on  some  patients  for  croup,  who  had  been  tracheotomized  quite 
a  long  time  previously,  for  the  same  cause.  I  have  met  some 
cases  of  a  second  attack  of  croup,  but  the  second  has  not,  as 
the  first,  required  tracheotomy ;  it  has  always  been  benign;  in 
three  cases  it  returned ;  to  wit,  in  one  of  them  after  one  year, 
in  the  others  nineteen  days  after  the  recovery  of  the  first. 
Croup  not  operated  has  furnished  a  larger  number  of  return 
cases.  The  return  has  not  always  followed  croup,  but  also  an- 
gina only.  In  ten  return  cases,  five  attacked  the  larynx,  the 
others  were  limited  to  the  tonsils.  They  appeared  from  the 
fourth  to  the  twentieth  day.  They  were  all  benign.  Except 
in  one  case  which  depended  upon  an  infectious  diphtheria 
there  was  no  occasion  to  operate. 

COMPLICATIONS. 

All  the  complications  which  depend  upon  diphtheritic  poi- 
soning appear  also  in  croup.  They  have  reference  to  the  blood, 
the  nervous  system,  the  digestive  apparatus,  the  lymphatics, 
etc.  I  have  already  described  them,  and  it  will  be  sufficient 
here  to  mention  them.  Others,  although  making  a  part  of  the 
train  of  diphtheria,  and  remaining  liable  to  figure  -in  all  the  lo- 
calizations of  this  disease,  assume,  however,  more  intimate  re- 
lations with  croup,  of  which  they  are  the  true  complications. 
I  now  speak  of  the  lesions  of  the  respiratory  apparatus. 

A  third  group  is  composed  €>f  diseases  entirely  foreign  to 
diphtheria,  such  as  the  eruptive  fevers,  typhoid  fever,  etc., 
which,  in  the  hospitals  especially,are  found  so  frequently  in  the 
course  of  croup.  Of  course  I  shall  not  consider  as  complica- 
tions the  other  localizations  of  diphtheria,  viz.,  angina,  coryza 
and  pseudo  membranous  bronchitis  which  may  co-exist  with  it. 

I. — Complications  Affecting  the  Respiratory  Apparatus. 
These  implicate  the   larynx,  the  trachea,  the  lungs  and  the 
pleura. 

LARYNX. 

The  lesions  which  reach  the  larynx  are ; 
I.  Ulcerations    similar   to   those  which   affect  the   trachea; 
their  description  will  be  the  same  with  those  of  the  ulcerations 


LOCALIZATION    OF    DIPHTHERIA.  22/ 

of  that  organ.  It  may  be  proper  to  say  here  that  they  are  pri- 
mary, or  are  due  to  the  extension  of  those  from  the  trachea. 
Sometimes  they  are  deep  and  produce  necrosis  of  the  car- 
tilages. 

2.  Muscular  lesions  caused  by  the  propagation  of  inflamma- 
tion from  the  mucous  membrane  to  the  muscles.  These  altera- 
tions are  not  incurable,  but  they  cause  a  persistence  of  the  res- 
piratory and  phonetic  disturbances  for  a  long  time  after 
the  separation  of  the  false  membranes,  and  compel  the  patient 
to  retain  the  canula.  I  shall  consider  them  with  the  causes 
which  retard  the  removal  of  the  canula. 

3.  OEdema  of  the  glottis,  polyps  of  the  larynx  of  which  the 
study  will  also  be  treated  in  the  same  chapter. 

TRACHEA. 

They  are  of  two  kinds,  traumatic  and  ulcerous. 

1.  Traumatic .  These  are  the  ruptures  which  are  produced 
under  the  influence  of  paroxysms  of  suffocation.  Latour  has 
cited  a  remarkable  case  of  it.  Traumatic  emphysema  is  the 
consequence  of  this  solution  ef  continuity. 

2.  Ulcerous.  These  are  the  more  frequent.  They  are  known 
under  the  name  of  ulcerations  of  the  trachea.  In  a  previous 
work  I  made  a  monograph  of  these  ulcerations.  I  will  give 
them  a  resume,  modified  slightly  in  consequence  of  later  ob- 
servations, in  the  part  which  will  treat  of  the  sequences  of 
tracheotomy.  There  will  be  found  the  place  of  these  lesions 
which  are,  in  the  great  majority  of  cases,  the  result  of  pressure 
of  the  canula. 

LUNGS    AND    PLEURA. 

The  pulmonary  complications  are  :  Simple  bronchitis,  bron- 
cho-pneumonia, pulmonary  congestion,  pneumonia,  pleuritis, 
emphysema,  apoplexy,  gangrene  and  oedema.  In  the  chap- 
ter on  the  pathological  anatomy  I  have  described  the  lesions 
which  correspond  to  these  complications,  have  noted  their  fre- 
quence, and  established  their  pathogeny.  I  have  proved  that 
several  of  these  morbid  states  should  be  considered,  less  as 
complications    developing   themselves    under  an    exterior   in 


228  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

flucnce,  than  as  diphtheritic  manifestations  arrested  in  develop- 
ment, or  as  congestions  or  visceral  inflammations  which  arise 
in  diphtheria  as  in  typhoid  fever  and  in  general  diseases.  In 
this  light  it  is  better  to  regard  the  bronchitis  and  broncho 
pneumonia.  Others,  such  as  pneumonia,  pleurisy,  gangrene 
and  oedema,  give  evidence  of  propagation  to  the  pulmonar\ 
parenchyma  ;ind  to  the  pleura,  of  this  inflammatory  condition, 
limited  at  first  to  the  mucous  membrane  of  the  bronchi.  Tht 
emphysema  proceeds  from  the  respiratory  restraint ;  the  ap- 
oplexy is,  at  the  same  time,  connected  with  the  asphyxia  and 
the  infection. 

I  have  also  demonstrated  by  figures  that  these  complication.- 
were  not  under  the  special  influence  of  tracheotomy ;  that  in 
the  cases  in  which  autopsies  were  made  the  lesions  had  been 
ascertained  at  a  period  sufficiently  near  to  the  beginning  to 
justly  admit  of  their  frequently  being  attributed  rather  to  the 
development  of  the  morbid  process  than  to  the  operation.  To 
these  evidences  we  might  add  others.  Croup,  not  operated  on, 
diphtheritic  angina  alone,  and  even  isolated  diphtheritic  coryza, 
are  accompanied  with  these  same  pathological  conditions.  On 
the  other  hand,  comparative  pathology  proves,  as  Duhomme 
has  observed,  that  the  pulmonary  phlegmasiae  are  very  rare  in 
those  who  have  undergone  tracheotomy  for  any  other  disease 
except  croup.  The  period  at  which  the  complication  is  diag- 
nosticated during  life,  confirms,  as  I  shall  prove  later,  this  view 
of  the  subject.  I  shall  develop  these  arguments  more  fully 
when  I  shall  treat  of  the  sequences  of  tracheotomy.  Let  us 
recognize,  however,  that,  if  this  operation  is  not  the  special 
cause  of  these  phlegmasiae,  it  has,  however,  its  part  in  their 
production.  The  proof  of  it  is  in  the  diminution  of  these  com- 
plications since  the  use  of  the  cravat  has  prevented  the  cold 
and  dry  air  from  reaching  the  bronchial  mucous  membrane. 
Before  this  practice  nearly  all  the  patients  succumbed  to  bron- 
cho-pneumonia. This  was  the  cause  of  numerous  failures, 
which  at  the  beginning  nearly  compromised  an  operation  which, 
since,  has  restored  to  life  so  many  patients.  It  is  curious  to 
observe    the    increasing   progress    of  success  coincident  with 


LOCALIZATION    OF    DIPHTHERIA.  229 

the  more  skilful  application  of  the  after-treatment,  especially 
now  that  the  field  of  contra-indications  is  being,  little  by  little, 
considerably  restricted,  we  operate  on  a  multitude  of  patients 
that  would  have  been  abandoned  a  few  years  since.  I  shall 
still  have  to  set  forth  the  symptoms  of  these  complications 
wherein  they  have  relation  to  croup,  and  to  show  their  influ- 
ence upon  the  course  of  the  disease. 

Before  proceeding  farther  it  will  be  proper  to  say  a  few 
words  respecting  auscultation  in  subjects  attacked  with  cro7ip, 
zvliether  operated  or  not.  We  encounter  in  this  study  difficul- 
ties of  which  we  must  be  informed. 

It  is  only  necessary  to  place  the  ear  over  the  chest  of  one  of 
these  patients  to  learn  how  difficult  it  is  to  recognize  the  estab- 
lished stethoscopic  signs.  Before  the  operation  the  difficulty 
arises  from  incomplete  entrance  of  air  into  the  chest;  the 
signs  which  might  reveal  a  pulmonary  lesion  are  lost  in  the 
general  silence  or  are  masked  by  the  laryngo-tracheal  wheez- 
ing which  resounds  in  the  chest  to  such  a  degree  as  to  drown 
all  other  sounds.  By  its  intensity  and  by  the  character  which 
it  assumes  on  auscultation,  this  phenomenon  may  give  rise 
to  certain  errors.  Slightly  intense,  it  has  a  certain  re- 
semblance to  the  respiratory  murmur.  This  analogy,  it  is 
true,  is  imperfect  but  an  ear  unaccustomed  to  this  kind  of 
auscultation  may  be  deceived;  I  have  seen  persons  experi- 
enced in  ordinary  auscultation  commit  this  error.  Such  a 
mistake  may  be  fatal  to  a  patient  by  authorizing  irreparable 
delay  of  an  urgent  operation.  A  careful  auscultation  always 
enables  one  to  distinguish  the  two  sounds.  When  the  air 
enters  the  chest  one  hears  the  murmur  which  characterizes  the 
opening  of  the  vesicles  ;  when  it  does  not  enter,  or  enters  but 
little,  one  is  assured  that  the  sound  heard  does  not  arise  under 
the  ear,  but  is  only  the  re-echo  of  the  wheezing  produced  in 
the  larynx.  When  the  wheezing  is  very  intense,  it  has  the 
character  of  the  bronchial  souffle,  also  an  error  to  be  avoided  ; 
this  is  perhaps  the  most  difficult.  The  comparison  of  the  two 
sides  and  percussion  will  assist  in  recognizing  the  nature  of 
the  sounds.     In  cases  in  which  the  reverberation  is  feeble,  one 


230  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

may  perceive  the  murmur  (rales)  if  they  exist.  We  see  how 
little  confidence  can  be  placed  on  the  stethoscopic  phe- 
nomena. The  only  symptoms  which  cause  suspicion  of  the 
development  of  a  thoracic  complication,  are  the  frequency  of 
the  pulse  and  respiration  and  the  elevation  of  temperature.  If 
the  difficulty  is  great  in  distinguishing  the  sounds  which  oc- 
cur within  the  bronchial  tubes,  what  will  not  that  be  which  at- 
tends the  examination  of  the  sounds  of  the  heart! 

Percussion  may  render  some  service  only  in  the  cases  in 
which  it  reveals  a  very  evident  and  quite  localized  difference 
in  the  sonority.  Differences  less  marked  are  often  causes  of 
error,  and  are  remarkable  for  their  great  instability.  After 
the  operation  air  penetrates  the  chest,  but  auscultation  en- 
counters other  obstacles  no  less  potent,  to-wit,  the  sounds 
which  come  from  the  canula.  Whether  these  sounds  be 
whistling,  or  gurgling,  or  rattling,  etc.,  they  extinguish,  none 
the  less,  if  somewhat  intense,  those  which  are  produced  in 
the  lungs  and  in  the  heart.  The  principal  is  a  whistling  with 
a  metallic  ring,  which  one  may  easily  take  for  the  bronchial 
souffle.  When  the  canular  sounds  are  moderate  the  stetho- 
scopic signs  are  heard  more  easily.  The  details  are  well  to 
know  in  order  to  fi.x  the  diagnosis ;  it  presents  many  diffi- 
culties ;  the  rational  signs  indicate  it,  but  the  physical  signs 
often  fail.  Since  the  canula  can  be  removed  for  a  few  mo- 
ments without  inconvenience,  it  is  necessary  to  withdraw  it 
while  one  auscultates  the  chest.  This  is  the  only  means  ot 
judging  whether  the  respiration  is  clear  and  full,  and  of  recog- 
nizing abnormal  sounds. 

Connnoii  Characteristics.  The  Beginning. — Croup,  under 
ordinary  conditions,  gives  rise  to  moderate  fever.  The 
pulse  varies  between  96  and  120  in  the  child,  and  be- 
tween 72  and  80  in  the  adult.  Respiration,  while  slightly 
accelerated,  remains  in  the  neighborhood  of  36  to  48  in  the 
minute;  and  finally,  the  temperature  does  not  exceed  38°  or 
38.5°  (100°  to  101'/,°)-  As  soon  as  a  thoracic  phlegmasia 
arises,  the  fever  lights  up,  the  pulse  rises  to  120  or  to  160,  the 
respiration  to  50  or  60,  and  the  temperature  to  39.5°  (103°)  or 


LOCALIZATON    OF    DIPHTHERIA.  23 1 

1040*^  ("04°)  or  higher.  If  this  onset  is  near  the  beginning  of 
the  disease,  the  transition  is  imperceptible,  and  the  patient 
appears  with  this  symptomatic  development  which  of  itself,  in 
the  absence  of  every  sign  furnished  by  auscultation,  is  a 
certain  index  of  a  lesion  of  this  nature.  Should  it  be  later, 
then,  to  a  condition  almost  apyretic  succeeds  a  febrile  state, 
and  oppression  accompanied  sometimes  by  vomiting  and  con- 
vulsions. These  common  characters  being  indicated,  I  coifie 
to  each  complication  in  particular.  Let  us  observe,  before 
going  farther,  that  these  morbid  conditions,  being  often  asso- 
ciated, as  anatomical  examination  has  proved,  the  symptoms 
peculiar  to  each  are  rarely  distinct;  they  are  very  commonly 
confounded,  the  more  feeble  masked  by  the  more  prominent. 
I.  Simple  Bronchitis. — Nothing  distinguishes  it  from  ordi- 
nary bronchitis ;  during  the  asphyxial  period  of  croup  its 
symptoms  are  veiled  by  the  laryngo-tracheal  wheezing;  the 
small  quantity  of  air  which  enters  the  chest  communicates  to 
the  chest-walls  and  to  the  bronchial  liquids  only  vibrations 
insufficient  for  the  production  of  physical  phenomena.  After 
tracheotomy,  one  may,  by  taking  proper  precautions,  perceive 
the  signs  furnished  by  auscultation.  When  it  is  limited  to  the 
large  tubes  and  is  superficial,  fever  and  oppression  are  moder- 
ate, expectoration  soon  becomes  decidedly  mucous,  and  the 
prognosis  appears  favorable.  If  more  intense,  it  gives  rise  to  a 
quite  abundant  muco-purulent  expectoration,  which  is  often 
expelled  at  the  moment  when  the  trachea  is  opened.  Its  ex- 
tension to  the  bronchioles  presents  a  more  severe  character, 
the  fever  and  the  oppression  increase,  the  expectoration  is 
diminished  which  gives  rise  to  the  expression,  the  ca/nila  is 
dry.  The  prognosis  becomes  more  doubtful  not  only  because 
of  the  addition  to  the  croup  of  a  condition  which  of  itself  is 
not  devoid  of  gravity,  but  because  this  bronchial  phlogosis  is 
often  only  the  first  stage  of  broncho-pneumonia  or  of  pseudo- 
membranous bronchitis,  both  so  much  to  be  dreaded.  Simple 
bronchitis  should  not  be  confounded  with  another  thoracic  af- 
fection. One  should  not  take  for  rales  which  characterize  it, 
certain  coarse  and  dry  sounds  analogous  to  the  pleural  frictions* 


232  DIPHTHERIA,  CROUP  AND  TRACHEOTOMY. 

indications  sufficiently  common  of  bronchial  diphtheria  at  the 
begfinninp;.  When  it  coincides  with  other  thoracic  lesions, 
which  often  happens,  it  remains  decidedly  in  obscurity. 

2.  Broncho-Pneumonia. — According  to  results  furnished  by 
anatomical  examination  we  see  that  the  characteristic  lesions  of 
broncho-pneumonia  are  found  in  the  earlier  stages  of  the  dis- 
ease, that  is  from  the  third  to  the  sixth  day.  Investigations 
nicSde  during  life  confirm  in  every  respect  these  results.  The 
diagnosis  has  been  fixed  at  the  following  dates: 

[Of  129  cases  98  occurred  within  the  first  nine  days].  The 
greatest  number  of  cases,  therefore,  is  also  found  at  the  com- 
mencement of  the  disease,  from  the  second  to  the  seventh 
day,  with  this  peculiarity,  that  the  second  day  is,  with  the  fifth 
and  the  sixth,  the  one  which  corresponds  to  the  highest 
figures. 

I  have  also  made  a  counter  evidence  in  respect  of  the  in- 
fluence of  tracheotomy  in  the  production  of  broncho-pneumo- 
nia. The  post-mortem  results  have  proven  that  taken  in  its  re- 
lation to  tracheotomy,  broncho-pneumonia  was  established  ana- 
tomically, especially  in  the  first  two  days  which  followed  this 
operation.  The  examination  during  life  led  to  the  same  con- 
clusions. 


Period  when  the  diagnosis 

Number  of 

Period  when  1 

he  diagnosis 

Number  of 

was  made. 

cases. 

was  made. 

cases. 

Evening  of  the 

operation. 

4 

9th  day 

- 

3 

1st  day 

- 

19 

loth  " 

- 

I 

2d     " 

- 

44 

nth  " 

- 

I 

3d     " 

- 

1 1 

1 2th  " 

- 

I 

4th    " 

- 

4 

13th  " 

- 

2 

5th    " 

- 

6 

14th  " 

- 

2 

6th    " 

- 

3 

15th  " 

- 

2 

7th   " 

- 

2 

18th  " 

- 

2 

8th    " 

- 

2 

25th  " 

- 

I 

Tetal,  -  -  -  -  -  no 

The  first  two  days  have  manifestly  the  highest  numbers. 
The  data  furnished  by  the    examination    of  the    patient    ac- 
cord, therefore,  with  those  from  pathological  anatomy.  Trache- 


LOCALIZATION    OF    DIPHTHERIA.  233 

otomy  is  certainly  not  the  only  cause  of  broncho-pneumonia. 
This  pulmonary  inflammation  developes  itself  at  the  begin- 
ning of  the  disease,  when  the  process  is  in  al'  its  power,  then 
it  rapidly  diminishes  in  frequence  at  the  end  of  a  few  days. 
The  symptoms  of  broncho-pneumonia  are  often  obscured  dur- 
ing the  period  of  asphyxia  of  croup.  It  is  only  after  the  op- 
eration that  it  is  practicable  to  fix  the  diagonosis;  to  the  fever, 
and  oppression  are  added  the  signs  furnished  by  auscultation 
and  percussion,  viz.,  sub-crepitant  rales,  bronchial  souffle,  and 
dullness.  In  the  absence  of  others  one  of  the  most  reliable  symp- 
toms is  the  acceleration  of  respiration.  Millard  has  established 
correctly,  that  one  may  suspect  a  pulmonary  inflammation 
every  time  when  the  respiration  exceeds  50  inspirations  in  the 
minute. 

htiology. — Though  it  is  not  doubtful  that  broncho-pneumo- 
nia is  one  of  the  accessories  of  the  diphtheritic  impulsion,  yet 
one  may  not  deny  the  action  of  cold  in  its  production.  The 
want  of  proper  care  in  tracheotomies  powerfully  favors  it.  In 
cases  especially,  which  arise  at  a  period  remote  from  the  be- 
ginning, when  the  first  effort  is  declining,  it  is  difficult  not  to 
assign  an  important  place  to  this  influence.  The  inspiration  of 
an  atmosphere  too  cool  through  the  canula  or  by  the  wound, 
contact  of  the  cutaneous  surface  with  air  insufficiently  warmed, 
are  its  principal  modes.  Anaemia,  and  the  general  shock  which 
follows  croup,  render  patients  very  sensible  to  external  in- 
fluences. 

Prognosis. — The  gravity  of  broncho-pneumonia  in  case  of 
croup  is  excessive,  and  so  much  the  more  as  it  is  often  accom- 
panied with  other  grave  lesions,  viz.,  pseudo-membranous 
bronchitis,  pneumonia,  pulmonary  apoplexy,  gangrene,  etc. 
This  it  is  which  carries  off  the  largest  number  of  tracheoto- 
mized  cases  ;  in  199  cases  of  broncho-pneumonia  only  eight  were 
able  to  reach  recovery.  It  is  dreaded  at  all  periods  of  the  dis- 
ease. At  the  beginning  its  gravity  is  not  always  revealed  very 
plainly  in  the  midst  of  the  symptomatic  confusion,  sometimes 
so  complex,  which  characterizes  this  period,  but  it  appears  in 
plain  view  when,  supervening  in  a  patient  nearly   well,  it    sud- 


234  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

denly  destroys  an  edifice  erected  at  a  cost  of  persistent  labor 
and  incessant  solicitude.  Of  the  eight  cases  of  recovery  of 
which  I  have  spoken,  three  corresponded  to  the  third  day  of 
the  disease,  two  to  the  fourth,  one  to  the  fifth,  one  to  the  thir- 
teenth and  one  to  the  fourteenth.  Thus,  of  the  numerous  cases 
developed  from  the  fifth  to  the  forty-first  day,  we  find  only  two 
recoveries. 

3,  Pulmonary  Congestion. — Rarely  found  alone,  it  must  be 
nearly  always  reckoned  with  other  more  serious  lesions  ;  often 
precedes  them.  When  the  croup  is  simple,  it  (the  former)  is 
the  result  of  asphyxia  ;  the  cyanosis  is  one  of  the  signs  which 
reveal  it.  Auscultation  tells  nothing  because  of  the  difficulty 
of  respiration.  It  disappears  after  tracheotomy.  When  it  co- 
incides with  other  grave  pulmonary  lesions  it  is  consigned  to  a 
second  rank  and  disappears  in  the  whole.  Finally,  in  certain 
cases  of  profound  infectious  diphtheria,  it  exists  alone  as  in 
typhoid  fever  and  other  diseases  of  like  nature.  It  is  recog- 
nized by  its  ordinary  signs,  viz.,  subcrepitant  rales  more  or  less 
extended,  with  corresponding  dulness.  The  gravity  of  the 
situation  depends  then  upon  the  general  condition.  Pulmo- 
nary congestion  can  claim  only  the  position  of  an  epiphenome- 
non.  It  is,  after  all,  a  secondary  element  which  complicates 
several  morbid  conditions,  whether  it  preceds,  accompanies  or 
follows  them.  It  contributes  to  each  its  contingent  of  aggra- 
vation ;  but  it  has  no  morbid  personality. 

4.  Pneumonia. — The  symptoms  of  pneumonia  appear  also  in 
the  early  days  of  croup.  From  the  second  to  the  fifth  day  the 
cases  were  most  numerous. 

In  a  list  of  twenty  cases,  eight  cases  of  croup  are  included 
not  operated  on.  It  is  proper  to  remark  that  pneumonia  ap- 
peared once  in  one  case  of  diphtheria  limited  to  the  throat. 
In  regard  to  its  relation  to  tracheotomy,  pneumonia  furnishes 
analogous  results : 


LOCALIZATION  OF  DIPHTHERIA. 


235 


Date  of  the  Diagnosis. 


1st  day  before  tracheotomy, 
1st  day  of  tracheotomy, 


2d 

<<               << 

3d 

«               It 

4th 

«                              <4 

5th 

«                              « 

7th 

It                            H 

8th 

It                            H 

loth 

u                          << 

71st 

<(                          <( 

Total, 


No.  OF  Cases. 
2 
2 
2 
I 
I 
I 
I 
2 


15 


The  intensity  of  the  symptoms  of  pneumonia  enables  it  to  be 
more  easily  distinguished  than  other  complications.  Thus 
diagnosis  coiild  be  formulated  twice  before  tracheotomy  and  in 
several  other  cases,  notwithstanding  the  coexistence  of  other 
serious  pathological  conditions,  such  as  pseudo-membranous 
bronchitis  and  broncho-pneumonia.  Therefore,  there  exist 
no  difficulties  in  this  respect.  Pneumonia  runs  its  course  with' 
more  or  less  rapidity,  depending  upon  whether  it  ends  in  reso- 
lution, passes  to  suppuration,  or  causes  death,  while  remaining 
in  the  second  degree.  The  prognosis  is  grave  ;  in  forty-eight 
cases  seven  only  recovered.  This  mortality  is  explained  by  the 
other  bronchial  lesions  which  exist  at  the  same  time,  and  of  which 
it  announces  the  propagation  to  the  pulmonary  parenchyma. 
The  facility  of  transition  to  the  third  degree  proves  the  intensi-. 
ty  often  assumed  by  the  pulmonory  inflammation,  since  in  thir- 
ty-two pneumonias  shown  at  the  autopsies,  nine  of  them  were 
in  the  stage  of  grey  hepatization.  Of  the  seven  recoveries, 
four  belonged  to  croup  not  operated  on ;  they  had  begun  re- 
spectively on  the  second,  third,  fifth  and  tenth  day  of  the  dis- 
ease. The  three  which  belonged  to  operated  croup  were  dis- 
covered on  the  preceeding  evening,  the  thirtieth  and  seventy- 
first  days  of  the  operation  respectively.  This  last  is  so  late  that 
it  might  be  considered  as  independent  of  croup,  and  as  purely 
accidental.     Thus,  in  eight  cases  of  pneumonia  supervening  in 


236  DIPHTHERIA,  CROUP    AND    TRACHEOTOMV. 

cases  of  croup  not  operated  on,  four  terminated  favorably.  In 
forty  occuring  in  tracheotomized  cases,  only  three  recovered. 
These  results  correspond  with  the  difference  in  gravity  which 
croup  presents  in  these  two  series,  and,  at  the  same  time,  with 
the  simplicity  of  pneumonias  in  the  first  as  opposed  to  their 
complexity  in  the  second. 

5.  Pleiirisy. — This  is  not,  properly  speaking,  a  direct  conse- 
quence of  croup,  but  an  extension  of  the  pulmonary  inflamma- 
tion to  the  pleura.  Ten  cases  of  pleurisy  in  twenty-nine  could 
be  recognized  during  life.  It  is  more  difficult  to  establish  ex- 
actly the  date  of  their  appearance;  the  commencement  passes 
often  unnoticed,  either  by  other  complications  existing  pre- 
viously and  obscuring  it,  or  by  its  slight  intensity  and  its  mild- 
ness attracting  attention  only  after  a  considerable  time. 

The  cases  indicate  a  certain  grouping  of  pleurisy  around  the 
first  days  of  the  disease,  but  several  of  them  are  disseminated 
without  apparent  order.  Besides,  it  is  natural  that  the  trans- 
mission of  the  pulmonary  lesions  to  the  pleura,  and,  therefore, 
the  beginning  of  the  pleurisy,  should  occur  at  variable  periods. 
The  diagnosis  is  often  rendered  obscure  by  the  coincidence  of 
other  pulmonary  lesions.  However,  the  classic  characteristics 
of  pleurisy,  which  I  need  not  recall,  permit  an  exact  estimation 
in  the  majority  of  cases.  Prognosis. — Of  twenty-nine  cases  of 
pleurisy,  the  recovery  was  effected  in  nine.  Of  these  nine 
cases,  eight  continued  during  the  active  part  of  the  trache- 
otomized croup.  This  reversing  of  the  ordinary  proportion, 
which  usually  gives  the  greater  number  of  deaths  on  the  side 
of  the  cases  of  tracheotomy,  shows  once  more  the  absence  of 
direct  dependence  between  croup  and  pleurisy.  The  pleural 
phlegmasia  is  especially  connected  with  other  pulmonary  in- 
flammations of  which  it  is  only  an  extension. 

6.  Pulmonary  EmpJiyscrna. — However  frequent  emphysema 
may  be,  it  is  very  difficult,  and,  so  to  speak,  impossible  to  as- 
certain its  presence  during  life.  The  symptoms  of  asphyxia 
and  those  of  the  other  pulmonary  complications  always  pre- 
vent its  recognition.  Besides,  it  is  never  sufficiently  intense, 
except  in  cases  of  traumatic    origin,  to   cause   suspicion  of  its 


LOCALIZATION    OF    DIPHTHERIA.  23/ 

presence.      Traumatic  emphysema  is  no  longer  a  complication 
of  croup,  but  an  accident  of  the  operation  of  tracheotomy. 

7.  Pulmonary  Apoplexy. — Respecting  this,  I  should  also 
limit  myself  to  what  I  have  said  of  the  anatomical  lesions,  and 
of  the  pathogeny.  Whether  it  be  the  result  of  asphyxia  or  of 
the  infection,  it  is  accompanied  by  other  lesions,  the  symp- 
toms of  which  mask  those  belonging  to  it.  In  a  case  of  diph- 
theritic paralysis,  extending  to  the  respiratory  muscles,  which 
terminated  by  asphyxia,  the  pulmonary  apoplexy  ascertained 
at  the  autopsy  furnished  no  s)'mptoms  during  life  except  slow 
dyspnoea  and  rales  of  bronchitis.  It  is  infrequent;  I  have 
only  met  with  it  eighteen  times. 

8.  Pulmonary  Gangrene — I  shall  say  the  same  of  gangrene ; 
its  history  has  more  connection  with  the  anatomy  than  with 
the  symptomatology.  Its  coincidence  with  broncho  pneu- 
monia has  always  rendered  its  beginning  obscure.  The  morti- 
fication of  the  tonsils,  of  the  uvula,  and  of  the  walls  of  the 
wound  in  the  neck,  may  point  in  the  direction  of  the  diagno- 
sis. But  how  frequent  are  these  cases  of  gangrene  compared 
with  those  of  the  lungs.  The  peculiar  odor  is  significant  only 
when  the  wound  and  the  throat  are  healthy.  The  only  symp- 
tom which  appears  to  have  any  value  is  the  profound  prostra- 
tion into  which  those  patients  sink  a  few  days  before  death, 
who  show  at  the  autopsy  the  lesions  of  pulmonary  necrosis. 
If  this  depression  appears  in  a  patient  already  attacked  with 
gangrene  of  the  wound  or  of  the  throat,  and  suffering  at  the 
same  time  oppression,  there  will  be  occasion  for  doubting  the 
existence  of  pulmonary  gangrene. 

9.  Pulmonary  CEdema. — This  form  of  dropsy,  probably  the 
result  of  the  impeded  circulation  of  the  lungs,  does  not  ordi- 
narily reveal  itself  by  any  external  sign.  However,  the  case 
observed  by  Traube  presented  some  interesting  peculiarities. 
A  woman,  in  the  ninth  month  of  pregnancy,  came,  com- 
pletely cyanosed  and  breathing  with  difficulty,  to  the  clinic  of 
the  professor.  False  membranes  lined  the  throat,  and  exam- 
ination with  the  laryngoscope  showed  that  they  extended  to 
the    larynx.     The   respiration   was   stertorous,    and    could    be 


238  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

heard  at  a  considerable  distance.  Tracheotomy  was  per- 
formed. An  unimportant  amelioration  was  the  immediate  re- 
sult. Then,  at  the  end  of  a  few  minutes,  the  patient  expelled 
through  the  canula,  without  the  efforts  of  coughing,  a  perfect 
flood  of  serosity.  Respiration  was  more  free,  and  the  stertor 
diminished.  But  in  the  evening  the  patient  was  delivered  of  a 
dead  child,  and  expired  a  few  moments  afterwards.  At  the 
autopsy  the  larynx  and  bronchi  were  found  lined  with  false 
membranes,  and  a  pneumonia  of  the  right  side,  but  only  traces 
of  pulmonary  oedema.  Should  we  in  this  case  regard  the 
oedema  of  the  lungs  as  existing  previously  to  the  tracheot- 
my,  or  as  an  infiltration  following  the  congestion  of  these 
organs?  I  should  be  so  much  the  more  inclined  to  admit 
this  latter  hypothesis  as  the  autopsy  showed  only  traces  of  the 
liquid  in  the  lungs.  An  oedema,  produced  under  the  influence 
of  pregnancy,  would  not  be,  from  all  aj^pearances,  evacuated 
so  suddenly  and  so  completely 

II.  Complications    Foreign   to   the    Disease    and    to    the 
L0C4L  Condition. 

Measles. — This  exanthema  sometimes  disturbs  the  course 
or  the  convalescence  of  croup,  especially  in  hospital.  Its  fre- 
quence is  inconsiderable ;  I  have  encountered  it  in  but  nine 
cases,  of  which  one  was  in  a  croup  case  not  operated  on. 
It  appeared  in  the  others  from  the  seventh  to  the  thirtieth 
day  of  the  operation. 

Date  of  the  Number  of     Date  of  the  Number  ot 

appearance.  cases.  appearance.  cases. 

7th  day  of  operation.     -      i  21st  day  of  operation.     -      i 

nth     "     «'  "  -     2         25th     "     "         "  -     I 

i8th     "     «  «*  .2         30th     "     «'         '.  _     I 

Total,  -..-.-  8 

To  these  eight  cases  I  will  add  the  croup  case  not  operated 
on,  in  which  the  measles  appeared  the  thirtieth  day  from  the 
beginning.  Twice  it  followed  a  case  of  scarlatina,  which 
itself  had  appeared  after  the  operation.     The  beginning  is  al- 


LOCALIZATIQN    OF    Dli'HTHERIA.  239 

ways  announced  by  fever  and  by  a  remarkable  arrest  of  the 
proces  of  cicatrization  of  the  wound  ;  it  may  even  occur  that 
the  wound,  entirely  cicatrized,  will  reopen.  The  bronchial 
symptoms  never  failed  ;  broncho-pneumonia  of  measles  car- 
ried off  the  largest  part  of  the  patients.  Death  was  the  ter- 
mination in  two-thirds  of  the  cases.  The  child  without  opera- 
tion succumbed  also  under  this  same  influence.  One  should 
anticipate  such  a  result  when  he  sees  the  measles,  a  disease 
which  exposes  so  seriously  the  bronchial  tubes,  follow  croup, 
which  spares  them  no  less.  The  prognosis  is,  therefore,  veiy 
grave,  which  is  so  much  the  more  to  be  regretted  because  the 
measles  levy  this  tribute  upon  patients  who  have  passed 
through  dangers  of  tracheotomized  croup,  so  terrible,  of  which 
the  recovery  was  almost  certain. 

Prophylaxis. — Isolation  of  patients  attacked  with  croup, 
especially  those  operated  on,  should  prevent,  as  far  as  it  is 
possible,  this  occurrence.  The  operated  patients  who  die  in 
this  way  are  victims  of  the  morbid  promiscuousness  which  ex- 
ists in  the  wards  of  the  hospital. 

Scarlatina. — This  eruption,  while  it  should  not  be  con- 
founded with  the  scarlatiniform  eruption,  which  appears  in  the 
course  of  diphtheria,  is  more  rare  than  measles,  which  is  in  ac- 
cordance with  the  inferiority  in  number  in  which  scarlatina  is 
found  proportionately  to  measles  as  to  general  frequence,  I 
have  collected  seven  cases  of  it.  It  appears  at  a  time  nearer 
the  beginning,  on  the  third  or  fourth  day  of  the  operation ;  in 
one  case  it  was  postponed  to  the  thirty-second  day. 

Date  of  its  Number  of    Date  of  its  Number  of 

appearance.  cases.  appeajance.  cases. 

3d    day   of   operation.     -     3         32d  day   of  operation.     -     i 

4th     "     "  "  -     2 

Total,  -  -  .  .  .  -  6 

The  patient  not  operated  on  was  taken  on  the  ninth  day 
from  the  commencement.  The  invasion  is  announced  like  that 
of  measles,  when  it  comes  on  sufficiently  slowly,  by  the  same 
disturbances  on  the  part  of  the  wound.  The  prognosis  is,  be- 
sides,  favorable,   recovery  having  occurred   in  all  the   cases. 


240  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

One  I  of  these  patients  sank  under  measles  which  he  contracted 
three  weeks  after  the  scarlatina. 

Erysipelas. — This  complication  being  peculiar  to  trache- 
otomized  croup,  I  shall  speak  of  it  in  detail  with  the  sequences 
of  the  operation. 

Whooping  Cough. — This  is  fortunately  very  rare ;  I  have  ob- 
served it  in  only  four  cases;  this  spasmodic  catarrh  attacks 
croup  cases  not  operated  on  as  well  as  those  on  which  the 
operation  of  tracheotomy  has  been  performed.  Two  cases  be- 
longed to  the  first  and  two  to  the  second  class.  In  the  first 
two  it  appeared  on  the  third  and  on  the  fourth  days  respect- 
ively from  the  beginning.  In  the  other  two  it  commenced  on 
the  day  before  the  operation  in  one  case,  and  five  days  after 
the  operation  in  the  other.  In  these  children  the  tW'O  diseases 
ran  a  parallel  course  in  its  development.  The  whooping  cough 
seemed  to  exercise  in  the  diphtheria  its  fatal  influence  upon 
the  bronchial  tubes.  The  four  patients  died  of  broncho-pneu- 
monia. Far  from  entailing,  as  usual,  a  certain  degree  of  suf- 
focation, the  paroxysms  did  not  render  the  attacks  of  dyspnoea 
more  numerous ;  several  of  them  were  not  followed  by  any  at 
all.  In  one  patient  only  certain  paroxysms  were  followed  by 
violent  fits  of  suffocation.  The  paroxysms  occasioned,  in  the 
tracheotomized  cases,  quite  a  curious  modification ;  the  char- 
acteristic wheezing  was  wanting.  The  prognosis  has  not  ap- 
peared equally  fatal  to  all  observers ;  several  cases  of  recovery 
have  been  reported. 

SEQUELS. 

When  the  false  membrane  separates,  the  inflammation  de- 
clines, the  croup  is  considered  as  cured  under  ordinary  circum- 
stances. It  is  quite  otherwise  in  those  in  which  the  respiration 
remains  difficult  and  the  voice  hollow.  These  prolonged 
difficulties  appertain  to  anatomical  lesions  which  I  have  already 
described.  The  persistence  of  the  tumefaction  of  the  laryngeal 
mucous  membrane  or  even  its  cedematous  infiltration,  and  the 
degeneration  of  the  laryngeal  muscles  are  so  many  causes  of 
oppression  and  roughness  of  voice,  which  continue  a  long  time 


LOCALIZATION  OF  DIPHTHERIA.  24I 

after  recovery.  The  cedema  of  the  glottis  is  with  difficulty- 
distinguished,  its  production  is  quite  rapid,  and  in  all  the  known 
cases  it  has  only  been  recognized  at  the  autopsy.  The  con- 
tinuation of  the  alterations  of  the  voice,  during  a  time  which 
varies  from  some  months  to  a  year,  is  due  to  the  tumefaction 
of  the  mucous  membrane  or  to  muscular  alteration.  The 
laryngoscope,  by  exhibiting  the  state  of  the  mucous  membrane 
and  the  action  of  the  muscles,  permits  an  elucidation  of  the 
question.  Other  accidents,  such  as  strictures  and  polypi  of 
the  trachea,  sometimes  follow  croup,  but  especially  croup 
tracheotomized.  I  shall  examine  them  in  connection  with  the 
sequences  of  tracheotomy. 

Section  III. — Diphtheritic  Coryza. 

One  of  the  first  symptoms  of  this  affection  is  obstruction  ac- 
companied by  a  certain  redness  of  the  nasal  orifices.  Very 
soon,  if  not  at  the  same  time,  there  escapes  a  nasal  discharge, 
serous,  mucous,  colorless,  thin,  yellowish  and  quite  often  san- 
guinolent;  it  exhales  a  peculiar  odor  which  may  be  quite  fetid, 
but  which  is  not  that  of  gangrene  nor  of  ozena.  At  a  period 
a  little  further  advanced  fragments  of  false  membranes  are  ex- 
pelled in  the  efforts  to  blow  the  nose.  At  first  small  in  quan- 
tity, the  discharge  forms  but  a  slight  oozing;  it  consists  entirely 
of  a  few  drops  of  clear  serosity  which  can  be  made  to  escape  by 
compressing  the  nose.  It  soon  increases  in  quantity  and  bathes 
the  upper  lip,  which  it  reddens  and  causes  to  swell.  The  patient, 
finds  himself  obHged  to  be  constantly  using  his  handkerchief. 
This  discharge  is  known  by  the  name  oijetage.  It  is  observed 
first  on  one  side  only:  sometimes  it  occupies  both,  either  pri- 
marily or  successively.  If  then  one  partially  opens  the  nostrils, 
he  sees  them  lined  internally  with  false  membranes, white,  thin, 
and  resistant  at  first,  but  yellowish  and  brown  later.  Exam- 
ination with  the  nasal  speculum  will  show  approximately  to 
what  point  the  nasal  fossae  have  been  invaded.  Frequently  the 
false  membrane  projects  from  the  nose,  and  it  is  seen  to  ex- 
tend upon  the  inferior  extremity  of  the  septum ;  it  may  reach 
still  farther  and  spread    upon  the   upper  lip.     The   alae  of  the 


242  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

nose  are  swelled ;  the  redness,  limited  at  first  to  their  borders, 
extends  and  reaches  the  nose  itself  the  skin  of  which  becomes 
tense  shining  and  erysipelatous.  It  is  not  uncommon  for  this 
redness  to  extend  on  the  face  beyond  the  nose.  Impermea- 
bility to  air  results  from  this  nasal  engorgement.  Respiration 
is  loud  and  snoring;  its  two  periods  are  of  equal  length.  The 
voice  has  a  nasal  tone.  The  patient  breathes  with  the  mouth 
open ;  the  teeth  and  lips  becoming  quickly  dry,  assume  a 
shiny  appearance  and  become  covered  in  places  with  thick, 
dark,  and  hardened  coatings.  These  respiratory  symptoms 
may  exist  without  any  false  membrane  being  visible,  notwith- 
standing the  use  of  the  speculum.  In  these  cases  the  poste- 
rior orifices  of  the  nasal  fossae  must  be  examined  by  introduc- 
ing the  rhinoscope  behind  the  soft  palate  ;  we  will  then  ob- 
serve false  membranes  coating  the  superior  portion  of  the 
pharynx  and  penetrating  into  the  nasal  fossae.  This  examina- 
tion is  possible  only  in  cases  in  which  the  tumefaction  and  the 
sensibility  of  the  throat  are  moderate.  To  the  morbid  phe- 
nomena just  enumerated  must  be  added  epistaxis  which  is 
one  of  the  usual  and  sometimes  grave  symptoms  of  diphtheri- 
tic coryza.  Often  slight  and  limited  to  a  simple  oozing  which 
darkens  the  discharges,  it  quite  frequently  reaches  the  amount 
of  a  real  haemorrhage.  It  is  rare  that  diphtheria  remains  limi- 
ted to  the  nasal  fossae.  At  one  time  it  extends  into  the  nasal 
duct  and  excites  free  lachrymation,  then  it  passes  through  the 
puncta  lachrymalia  and  expands  upon  the  conjunctiva.  At 
another  it  reaches  the  pharynx  and  travels  up  the  Eustachian 
tube  to  the  middle  ear.  But  the  parts  for  which  it  has  the 
greatest  affinity  are  the  throat  and  larynx.  Bretonneau  has 
generalized  this  fact  by  demonstrating  that  angina  and  croup 
were  always  preceded  by  diphtheritic  coryza.  According  to 
him,  the  nasal  fossae  were  the  nidus  whence  the  diphtheria 
spreads.  He  then  proceeds  to  affirm  that  this  disease  propa- 
gates itself  from  the  higher  parts  to  those  more  dependent. 
The  history  of  diphtheritic  angina  and  of  croup  more  than  proves 
that  this  rule  has  many  exceptions.  Diphtheritic  coryza  is  very 
frequently  followed  by  angina  and  croup,  but   it   is  not   rarely 


LOCALIZATION     OF    DIPHTHERIA.  243 

consecutive  to  angina,  or  is  developed  at  the  same  time  with 
it,  which  former  case  is  the  most  frequent.  Aside  from  all 
propagation  by  contiguity,  we  find  other  diphtheritic  manifes- 
tations at  distant  points  of  the  economy.  Thus,  diphtheritic 
coryza  frequently  coincides  with  the  formation  of  false  mem- 
branes upon  the  skin,  upon  the  genital  organs,  the  anus,  or 
upon  the  lips  and  tongue,  and  sometimes  in  the  bronchial  tubes 
without  the  medium  of  the  larynx  and  trachea.  The  general 
symptoms  which  accompany  diphtheritic  corzya  are  those  of 
infectious  or  malignant  diphtheria.  This  localization  has  been 
justly  considered  as  one  of  the  most  serious,  one  which  best 
characterizes  diphtheritic  infection  (Barthez  and  Trousseau), 
Excepting  the  rare  cases  in  which  the  false  membrane  does  not 
extend  beyond  the  nose,  or  in  which  other  manifestations  do 
not  arise  in  various  regions,  diphtheritic  coryza  is  always  a  very 
grave  prognostic.  When  death  is  not  the  result  of  infection  or 
of  propagation  to  the  air-passages,  epistaxis  is  one  of  its  fre- 
quent causes.  The  coincidence  of  coryza  with  other  diphtheri- 
tic manifestations  makes  its  duration  difficult  to  prove.  How- 
ever, Barthez  and  Rilliet  mention  two  cases  in  which  it  ended 
in  three  days.  On  the  other  hand,  Isambert  has  spoken  of  a 
patient  who  expelled  false  membranes  for  several  months  when 
blowing  his  nose.  Excepting  this  case,  diphtheritic  coryza  is 
acute,  and  does  not  appear  to  be  accompanied  with  ulceration 
of  the  mucous  membrane ;  it  attacks  neither  the  cartilages  nor 
the  bones  of  the  nose.  It  is  observed  at  all  ages,  but  it  is  more 
frequent  in  children 

Section  iv. — Pseudo -Membranous  Bronchitis. 

The  aspect  of  bronchial  diphtheria  varies  according  as  it 
coincides  or  not  with  croup,  as  it  is  observed  before  or  after 
tracheotomy.  One  might  suppose  at  first  sight,  that,  consider- 
ing it,  independent  of  croup,  or  indeed  in  croup  tracheoto- 
mized,  the  air  penetrating  the  chest,  it  would  present  itself  with 
its  peculiar  characteristics.  There  is  nothing  more  frequent, 
because  of  other  lesions  which  run  concurrently  with  it.  In 
the  description  of  symptoms  I  shall    establish    two    categories. 


244  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

In  the /■;-j>7  will  be  found  bronchial  diphtheria  accompanying 
croup  as  it  is  before  the  operation.  In  the  second  I  shall  place 
bronchial  diphtheria  without  the  intervention  of  croup  and 
that  which  is  observed  in  croup  after  the  operation.  The  ab- 
sence of  the  laryngeal  obstruction  on  the  one  hand,  its  removal 
by  the  operation  on  the  other,  allow  the  two  latter  forms  of 
pseudo-membranous  bronchitis  to  be  placed  side  by  side. 
When  bronchial  diphtheria  exists  in  a  patient  attacked  with 
croup  and  not  operated  upon,  it  signalizes  itself,  aside  from  the 
local  and  general  symptoms  of  croup  and  of  diphtheria  by  a 
notable  acceleration  of  the  respiration:  the  number  of  inspir- 
ations is  from  50  to  60  per  minute.  Dyspnoea  is  considerable, 
but  it  loses  the  intermittent  and  spasmodic  character  peculiar 
to  croup,  and  it  assumes  the  continued  type;  asphyxia  is  pro- 
duced slowly.  The  face  instead  of  being  cyanosed,  and 
turgescent,  is  pale;  the  lips  only  and  the  skin  under  the  nails 
are  bluish ;  the  eyes  are  dull,  and  the  patient  dejected.  The 
retraction  (tirage)  is  moderate.  This  form  of  dyspnoea  fur- 
nishes the  most  certain  sign  of  bronchial  invasion  with  false 
membranes.  Other  symptoms  are  of  great  value;  they  are 
furnished  by  auscultation  and  expectoration.  Auscultation 
rarely  furnishes  definite  signs;  the  respiratory  restraint  pro- 
duced by  the  laryngeal  obstacle  prevents  the  manifestation  of 
morbid  sounds  under  the  ear.  It  may  furnish,  however,  under 
certain  circumstances,  valuable  information.  When  the  exu- 
dation commences  and  reaches  only  the  large  bronchi,  one 
hears,  towards  the  root  of  the  lungs,  coarse  creaking  with  a 
dry  tone,  a  rubbing  sound  which  has  a  certain  analogy  with 
pleuritic  friction.  Later,  when  the  false  membranes  com- 
mence to  separate,  creaking  or  croaking  may  be  replaced,  ac- 
cording to  ancient  authors,  by  a  tremulous  or  flapping  sound.  I 
doubt  whether  this  sign  still  inspires  any  great  confidence. 
Fnally  if  the  false  membrane  extends  to  a  large  bronchial  di- 
vision, the  respiratory  murmur  is  notably  enfeebled  on  the  af- 
fected side.  In  the  absence  of  difference  in  percussion,  the 
inequality  of  vesicular  expansion  in  the  two  lungs,  is  one  of 
the  best  signs  of  pseudo-membranous  bronchitis,  at  least  at  the 


LOCALIZATION  OF    DIPHTHERIA.  245 

beginning.  Later  the  rubbing  sound  completes  the  picture. 
Tliese  symptoms  are  inconstant,  the  insufficient  access  of  air 
into  the  chest  often  prevents  them  from  being  perceived ;  the 
co-existence  of  another  pulmonary  lesion  masks  them  in  many 
cases.  The  expectoration  constitutes  the  best,  and,  so  to 
speak,  the  only  unobjectionable  sign.  That  is  the  only  lesion 
itself  which  comes  under  the  eye  of  the  observer  during  life. 
I  will  not  repeat  the  description  of  the  false  membrane  which 
may  be  expectorated;  it  will  be  found  under  pathological  an- 
atomy. At  the  time  when  expelled  the  false  membranes  are 
curled  up,  flattened,  and  sometimes  quite  resembhng  thickened 
mucus,  when  they  are  recent.  They  resume  their  form,  ar- 
rangement, and  characteristic  color  if  they  are  shaken  in  a 
glass  of  water.  When  bronchial  diphtheria  is  not  accompanied 
by  croup  or  if  it  follows  on  operated  croup,  the  signs  furnished 
by  auscultation  appear  in  all  their  clearness,  especially  during 
the  first  hours  following  tracheotomy.  But  it  is  necessary  to  this 
that  the  pseudo-membranous  bronchitis  should  not  be  compli- 
cated. Now,  we  have  seen  how  frequently  it  exists  with  such 
lesions  as  broncho-pneumonia,  pleurisy  and  pulmonary  apo- 
plexy. The  cases  are  rare  in  which  the  vascular  murmurs  and 
the  subcrepitant  rales  do  not  mask  the  symptom,  which  the 
bronchial  false  membranes  produce.  Moreover,  these  symp- 
toms are  uncertain;  one  is  reliable,  that  is  the  expulsion  of 
pseudo  membranous  fragments  forming  hollow  or  solid  cyl- 
inders, and  bands  or  threads.  When  it  is  somewhat  general- 
ized it  rapidly  leads  to  asphyxia.  It  may  occur,  however,  that 
the  expulsion  of  large  false  membranes  will  again  permit  the 
air  to  come  in  contact  with  the  bronchial  mucous  membrane, 
and  afford  decided  relief.  But  a  new  exudation  is  often  pro- 
duced ;  asphyxia  resumes  its  course  and  the  patient  succumbs. 
Of  all  the  pulmonary  lesions  this  most  certainly  leads  to  as- 
phyxia; it  is  with  this  that  we  most  frequently  encounter  sub- 
pleural  ecchymoses  and  even  true  infarctus.  When  localized,  it 
is  of  less  importance;  it  is  not  rare  to  see  patients  recover  who 
have  expectorated  false  membranes  of  considerable  size.  The 
termination,  most  common  of  pseudo-membranous   bronchitis. 


246  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

when  it  is  extensive,  is,  therefore,  death.  The  course,  when  it 
extends  over  a  large  surface,  is  rapid.  Asphyxia  is  its  speedy 
consequence.  The  description  which  I  have  given  of  the 
period  at  which  it  is  met  with  in  autopsy,  shows  that  it  has  been 
anatomically  verified  between  the  second  and  the  fifth  day  of 
the  diphtheria.  Now  as  it  is  rarely  one  of  the  diphtheritic 
manifestations  at  the  beginning,  we  may  conclude  that  its  de- 
velopment is  rapidly  effected.  In  cases  of  recovery,  it  some- 
times persists  a  very  long  time  :  I  saw  one  case  expectorate 
false  membranes  till  the  twenty-second  day.  I  would  not  af- 
firm that  in  this  case  the  concretion  belonged  to  the  bronchi; 
at  a  somewhat  distant  period  the  fragments  lost  their  characte- 
ristic form.  Others  expelled  tubular  false  membranes  the  same 
day  of  or  on  the  day  after  the  operation.  Between  these  ex- 
tremes lies  the  medium.  It  is  in  the  first  ten  days  that  the 
false  membranes  are  most  commonly  expelled.  When,  after 
this  relief,  the  respiration  remains  finally  calm,  and  auscultation 
furnishes  the  signs  of  integrity  of  the  bronchial  tubes ;  recov- 
ery may  be  considered  as  attained.  In  the  large  majority  of 
cases  bronchial  diphtheria  is  a  continuation  of  croup ;  the 
propagation  is  effected  by  contiguity  from  the  larynx  into  the 
bronchi.  This  connection  may  fail.  Still  more  rarely  pseudo- 
membranous bronchitis  exists  alone.  I  have  never  seen  such  a 
case,  and  I  should  be  tempted  to  believe  that  those  which  have 
been  cited  were  really  accompanied  by  croup  or  by  some  other 
unrecognized  diphtheritic  manifestation.  In  fact,  I  have 
always  found  with  it  one  of  these  localizations,  viz.,  coryza, 
conjunctivitis,  labial  or  lingual  diphtheria,  or  diphtheria  of  the 
skin,  the  genital  organs,  or,  finally,  angina.  In  these  cases  it 
is  accompanied  by  symptoms  of  maliginant  diphtheria ;  pros- 
tration, cachexia,  haemorrhages,  gangrene,  adenitis,  etc.  The 
details  respecting  the  treatment  show  that  the  diagnosis  of 
bronchial  diphtheria  is  possible  by  auscultation  only  when  it 
exists  alone.  Otherwise,  the  expulsion  of  tubular  or  branch- 
ing false  membranes  is  the  only  sign  of  value. 

The   prognosis    is    always  very    serious  when   bronchitis    is 
somewhat  extended,  particularly  when  it   is  complicated   with 


LOCALIZATION  OF  DIPHTHERIA.  24/ 

broncho-pneumonia  or  pneumonia.  The  gravity  resides  as 
well  in  the  imminence  of  asphyxia  as  in  the  profound  toxaemia 
of  which  bronchial  diphtheria  is  one  of  the  expressions.  Even 
when  slightly  extensive  it  is  always  dangerous  ;  and  it  is  an  ad- 
ditional element  of  asphyxia  when  there  is  croup ;  it  is  in  every 
case  a  sign  of  more  advanced  infection. 

Section  V. — Oculo-Palpebral  Diphtheria. 

{^Diphtheritic  Conjunctivitis^ 

The  study  of  this  form  of  diphtheria  has  engaged  a  certain 
number  of  authors.  To  the  names  of  Bouisson,  Laboulbene, 
Magne  and  Gibert,  whom  I  have  already  cited,  must  be  added 
those  of  Chassaignac,  Hutchinson.  Warlomont,  Wecker,  Peter 
and  Trousseau,  E.  H.  Martin,  Raynaud  and  Duplay.  Still 
rejected  by  a  few  authors,  by  MarjoHn  and  Lefort  especially, 
diphtheritic  conjunctivitis  is  accepted  by  the  large  majority  of 
observers  as  one  of  the  many  local  manifestations  of  diphtheria. 
The  appearance  of  this  form  of  diphtheria  is  something  quite 
sudden,  the  false  membrane  forming  rapidly,  the  lids  swelling 
considerably  and  exuding  an  abundant  discharge.  But  in  the 
ordinary  course  matters  transpire  differently.  The  onset  is 
slow,  the  disease  has  the  appearance  of  a  slight  ocular  affection. 
Coryza  opens  the  course;  followed  soon  by  redness  of  the  con- 
junctiva, swelling  of  the  lids,  and  with  discharge.  The  flow  is 
at  first  sero-mucous,  then  purulent,  but  it  very  soon  changes  in 
character,  and,  when  the  false  membrane  appears,  it  ceases  and 
the  eye  becomes  dry.  It  reappears  when  the  false  membrane 
separates.  The  variations  in  the  quantity  of  discharge  forms 
one  of  the  most  important  characteristics  of  ocular  diphtheria. 
This  liquid  is  acrid,  irritates  the  skin,  and  marks  its  way  by  a 
red  and  painful  streak.  The  lids  are  red,  swelled,  tense,  shiny, 
and  difficult  to  be  opened  for  examination.  Instead  of  being 
soft  and  oedematous  as  in  purulent  ophthalmia,  they  are  indu- 
rated, rigid,  and  appear  to  inclose  the  eye  in  a  resistant  hull. 
Pain  on  pressure  is  extreme.  Sometimes  it  is  quite  violent 
spontaneously,  but  in  many  cases  it  seems  to  pass  unnoticed. 
With  the  least  touch,  however,  it  becomes  intolerable  ;  the  use 


248  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY 

of  chloroform  then  becomes  indispensable  in  order  to  make  a 
complete  examination  of  the  conjunctiva.  The  heat  is  intense 
and  often  intolerable.  By  partially  opening  the  eye,  or  better, 
by  everting  the  lid  we  see  the  palpebral  conjunctiva  covered 
with  a  smooth,  thin,  false  membrane,  leaving  the  mucous  mem- 
brane visible  by  the  former's  transparency,  folding  with  the  lid, 
quite  adherent,  and  impossible  to  be  separated.  If  we  examine 
the  eye  at  an  earlier  period,  we  find  the  mucous  membrane 
smooth,  yellowish,  scattered  over  with  spots  of  pseudo-mem- 
brane which  soon  unite  to  form  a  general  uniform  false  mem- 
brane. 

The  palprebral  conjunctiva  alone  is  attacked,  at  least  pri- 
marily ;  the  ocular  conjunctiva  remains  healthy  or  is  infiltrated 
so  as  to  form  chemosis.  But  it  may  also  be  attacked  and  then 
become  coated  with  a  false  membrane  pierced  in  the  middle 
with  a  circular  opening  representing  the  situation  of  the  cor- 
nea. At  this  time  the  eye  is  almost  completely  dry  from  the 
compression  exerted  upon  the  vascular  system  and  upon  the 
conjunctival  glands  by  the  false  membrane.  However,  in  rais- 
ing the  lid  a  serous  liquid  escapes,  of  a  dull  gray,  formed  ot 
tears,  mucus,  epithelial  debris,  coloring  matter  of  the  blood, 
and  a  few  leucocytes.  At  the  end  of  a  period  varying  from  a 
few  hours  to  three  or  four  days,  the  false  m.embrane  commences 
to  separate  at  the  edges,  later  it  falls  off,  but  often  it  is  replaced 
by  another  ;  several  exudations  may  form  successively.  Finally, 
the  exudate  disappears  either  by  becoming  detached  or  reab- 
sorbed. With  its  detachment  a  notable  relaxation  of  the  con- 
junctival ischa^mia  coincides. 

The  ocular  mucous  membrane  again  becomes  red,  even  gran- 
ular ;  the  dryness  ceases,  and  the  secretions  reappear.  The 
discharge  becomes  at  first  like  it  was  in  the  onset,  then  it  as- 
sumes a  simple  purulent  appearance.  It  would  be  difficult  at 
this  period  to  distinguish  conjunctival  diphtheria  from  purulent 
ophthalmia.  But  it  is  at  the  very  moment  when  the  detach- 
ment of  the  false  membrane  gives  hope  of  the  happy  termina- 
tion of  the  disease,  that  grave  alterations  of  the  cornea  appear. 
The  compression  of  the  conjunctival  vessels  which  has  pro- 


LOCALIZATION  OF    DIPHTHERIA.  249 

duced  the  chemosis  and  restricted  the  nutrition  of  the  cornea, 
is  followed  with  opacity  and  even  real  necrosis  which  limits  it- 
self to  ulceration  or  extends  to  perforation  of  this  membrane. 
The  lesion  is  the  more  profound  in  proportion  as  the  compres- 
sion has  been  more  prolonged  and  intense.  Hernia  of  the  iris, 
staphyloma,  and  even  suppuration  of  the  ball  are  among  the  too 
frequent  terminations  of  this  process.  Whether  the  cornea  has 
degenerated  or  remained  sound  suppuration  gradually  dimin- 
ishes, the  granulations  cicatrize,  sometimes  without  leaving 
any  traces  ;  at  others,  if  the  reparation  is  irregular,  by  produc- 
ing either  entropion  or  ectropion.  Both  eyes  are  often  at- 
tacked, but  rarely  with  the  same  intensity ;  one  of  them  is  al- 
ways much  less  affected.  Local  diphtheria  of  all  kinds  may 
coincide  with  it,  to-wit,  croup,  angina  and  cutaneous  diphtheria. 
The  most  frequent  by  far  is  coryza. 

Grave  general  syviptojns  accompany  diphtheritic  conjunc- 
tivitis ;  it  is  not  often  observed  only  in  the  course  of  diphtheria 
of  the  most  infections  form.  It  is  not  at  all  surprising  that 
death  should  be  the  almost  constant  termination,  not  only  by 
the  profound  alterations  of  the  eye,  for  death  often  supervenes 
during  the  first  few  days,  before  perforation  of  the  eye  and 
suppurative  ophthalmitis,  but  because  of  the  gravity  of  the 
general  condition.  'W^q  duration  z2,nx\o\.  be  determined  as  in 
other  ocular  diseases,  because  of  the  importance  of  the  general 
symptoms  which  may  carry  off  the  patient  during  the  evolution 
of  the  disease.  In  cases  which  I  have  observed,  two  patients 
escaped  a  fatal  issue,  and  the  duration  of  ophthalmia  was  fif- 
teen days ;  in  two  others,  who  succumbed  to  the  diphtheritic 
infection,  when  the  eye  was  nearly  well,  it  was  from  the  twelfth 
to  the  seventeenth  day.  Duplay  estimates  it  geneaally  from 
the  fifteenth  to  the  twentieth  day. 

Prognosis. — It  follows  from  the  preceding  presentation  of 
symptoms  that  diphtheritic  conjunctivitis  is  of  serious  import- 
ance from  every  point  of  view,  as  far  as  concerns  the  local 
condition,  and  respecting  the  general  state  as  well.  In  twenty 
patients  which  I  have  observed,  nineteen  succumbed  to  diph- 
theritic infection.     These  cases,  not  occuring  in  the  same  year, 


250  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

and  not  belonging  to  the  same  epidemic,  preserve  all  their  fatal 
characteristics.  The  conclusions  of  Gibert  are  the  same.  It 
is  true  that  the  patients  seen  by  Gibert  and  by  myself  were 
nearly  all  attacked  with  secondary  diphtheria,  and  nearly  all 
consecutive  to  measles.  Graefe  rarely  saw  death  follow  this 
form  of  ophthalmia.  Were  all  the  cases  reported  by  him,  in- 
deed, under  the  influence  of  diphtheria  !  This  is  at  least  open 
to  doubt.  They  were  probably  cases  of  diphtheria  in  the 
German  sense  of  the  word.  When  death  can  be  avoided  the 
patient  seldom  escapes  serious  occular  changes.  The  figures 
presented  by  Graefe  prove  this  too  plainly.  Total  loss  of  the 
eye,  opacity  of  the  cornea,  and  anterior  synechia  are  frequent. 
Adults  were  attacked  even  more  severely  than  children.  The 
amount  of  fibrinous  infiltration  is  the  criterion  of  the  prog- 
nosis :  the  deeper  it  is,  the  more  the  circulation  is  obstructed, 
the  greater  are  the  dangers  of  destruction  (necrosis)  of  the 
cornea.  The  induration,  and  the  resistance  of  the  lids,  will 
furnish  the  best  information  in  this  respect.  The  rapidity  of 
its  course  possesses  much  value.  If  the  alteration  of  the 
cornea  commences  before  the  beginning  of  the  period  of  elim- 
ination of  the  false  membrane,  the  eye  is  irrevocably  lost.  If, 
on  the  contrary,  this  alteration  commences  only  after  the 
seventh  day,  the  prognosis  is  favorable.  In  conclusion,  oculo- 
palpebral  diphtheria  is  very  serious,  first,  because  it  is  the  indi- 
cation of  a  strongly  marked  infectious  state,  and  then,  because 
it  too  frequently  leaves  in  the  diseased  eye,  the  most  serious 
disturbances. 

Etiology. — It  is  in  the  infectious  and  malignant  forms  of 
diphtheria  that  it  is  usually  met  with,  and  especially  in  the 
secondary  forms,  and  particularly  in  those  consecutive  to 
measles.  In  fact,  it  should  be  observed  that  diphtheritic  oph- 
thalmia rarely  appears  in  primary  diphtheria.  It  selects  cases 
of  secondary  diphtheria,  not  only  those  which  come  after 
measles,  but  those  which  attack  patients  under  treatment  in 
hospital  for  various  morbid  conditi'^ns:  pleurisy,  paraplegia, 
tuberculosis,  etc.  Following  measles,  it  begins  from  the  third 
to  the  seventh  day  of  the  eruption.     When  secondary  to  other 


LOCALIZATION  OF    DIPHTHERIA.  2$  I 

diseases,  it  appears  from  the  seventh  to  the  thirteenth  day  from 
the  entrance  to  the  hospitals.  Age  has  a  manifest  influence. 
It  is  observed  between  one  and  ten  years.  However,  it  is  met 
with  in  the  adult,  but  rarely.  It  is  often  preceded  by  diph- 
theritic coryza,  particularly  when  it  is  associated  with  primary 
diphtheria.  Its  propagation,  appears  to  be  effected  by  the 
medium  of  the  nasal  duct. 

Section  vi. — Diphtheritic  Otitis. 

Diphtheria  attacks  the  superficial  as  well  as  the  deep  struct- 
ures of  the  ear.  The  sulcus  behind  the  ear  is  one  of  the 
places  of  election.  But  diphtheria  which  prevails  on  this 
^ace  being  rather  a  variety  of  cutaneous  diphtheria,  I  refer  it 
to  the  chapter  which  will  treat  of  this  localization.  Diphthe- 
ritic otitis  may  be  external  or  median ;  the  descriptions  of  ex- 
ternal otitis,  and  of  otitis  media  are  too  well  known  to  be  re- 
peated here.  I  shall  only  have  to  point  out  peculiarities  which 
they  present  when  they  are  dependent  upon  diphtheria.  These 
two  forms  of  otitis,  particularly  the  median  should  be  consid- 
ered in  their  etiological  relations  with  diphtheria,  the  symptoms 
being  almost  the  same  as  in  the  simple  cases. 

Otitis  Externa. — This  arises  by  extension  of  the  diphtheritic 
lesions,  originating  on  the  auricle  or  on  the  facial  integument 
which  surrounds  the  tragus.  Thence,  the  exudate  penetrates 
into  the  external  meatus  where  it  gives  rise  to  itching,  pain, 
tingling,  dulness  of  hearing,  and  a  sanious,  sanguinolent  dis- 
charge which  exhales  a  diphtheritic  odor.  Ordinarily,  this 
form  of  otitis  here  limits  itself;  it  may  inflame  the  membrana 
tympani ;  but  I  know  of  no  case  in  which  it  has  perforated 
thrs  membrane.  At  the  end  of  eight  or  ten  days  the  false 
membrane  separates,  sometimes  finally  and  sometimes  to  be 
replaced  by  one  or  several  other  exudations,  and  recovery 
takes  place,  unless  the  gravity  of  the  general  condition  leads 
the  disease  to  a  fatal  issue.  It  may  take  a  reverse  course.  In 
place  of  being  due  to  the  extension  of  diphtheria  from  the  sur- 
roundings of  the  ear,  it  depends  under  certain  circumstances, 
upon  the  extension   of  otitis  media. 


252  DIPHTHERIA,    CROUF    AND    TRACHEOTOMY. 

Otitis  Media. — This  is  much  the  more  frequent.  It  was  no- 
ticed by  Wreden  and  by  Duplay.  It  is  consecutive  to  diph- 
theria of  the  nasal  fossae  and  of  the  pharynx,  which,  by  in- 
sinuating itself  into  the  Eustachian  tribe,  ends  by  penetrating 
the  tympanum.  The  first  period,  that  of  invasion  of  the  tube 
and  of  the  middle  ear,  may  often  pass  unnoticed,  particularly 
in  young  children ;  pain  in  the  region  of  the  ear  is  complained 
of  by  those  who  are  old  enough,  and  it  is  aggravated  by  mas- 
tication, coughing,  blowing  the  nose,  and  is  confounded  with 
that  of  angina.  Attention  is  called  to  the  ear  in  many  cases, 
only  when  discharge  supervenes.  At  the  end  of  a  few  days 
the  pain  quite  suddenly  ceases,  and  one  perceives  upon  the 
ear  crusted  spots  of  moderate  extent  which  direct  attention  to 
the  examination  of  the  ear.  At  this  time  one  recognizes  the 
presence,  in  the  external  meatus,  of  a  sero-purulent,  slightly 
thick  fluid,  moderate  in  quantity,  fetid,  and  often  bloody. 
The  examination  with  speculum  shows  that  the  membrane  is 
perforated ;  and  one  frequently  discovers  at  the  bottom  of  the 
external  meatus  a  white,  thin,  false  membrane  which  extends 
sometimes  to  the  external  opening  of  this  canal.  Examination 
of  the  hearing  discloses  complete  deafness  of  the  affected  ear. 
Otitis,  thus  established,  follows  the  course  of  the  ordinary 
form.  At  the  end  of  a  variable  period  decline  occurs,  the  false 
membrane  becomes  detached,  discharge  diminishes  and  ends, 
in  certain  cases,  by  gradually  ceasing,  while  in  others  it  per- 
sists. But  when  it  ceases  entirely,  it  is  but  temporarily; 
changes  of  weather,  moisture  and  exposure  to  cold  frequently 
cause  it  to  return.  Hearing  returns  in  a  certain  measure,  but 
it  always  remains  imperfect  if  the  otorrhoea  has  continued  for  a 
long  time,  and  becomes  lost  every  time  the  latter  returns. 
Such  is  the  inevitable  ending  of  diphtheritic  otitis  when  the 
false  membrane  extends  into  the  tympanum.  When  it  is  lim- 
ited to  the  Eustachian  tube  its  symptoms  cannot  be  distin- 
guished, masked  as  they  are  by  the  symptoms  of  angina.  The 
disease  is  seldom  limited  to  one  ear  alone.  But  it  seldom  at- 
tacks both  with  the  same  degree  of  intensity.  Double  per- 
foration of  the  drum-membrane  is  relatively  not  very  common. 


LOCALIZATION    OF    DIPHTHERIA.  253 

It  may  coincide  with  a  great  number  of  diphtheritic  manifesta- 
tions. The  most  common  are  angina  and  coryza.  The  gen- 
eral symptoms  are  those  of  diphtheria,  sometimes  augmented 
by  certain  cerebral  symptoms  peculiar  to  otitis,  such  as  ver- 
tigo, vomiting,  insomnia,  delirium,  and  a  febrile  condition 
which  suddenly  raises  the  ordinary  thermic  curve  of  diph- 
theria. 

Prognosis. — From  a  local  point  of  view  the  prognosis  is  seri- 
ous. Perforation  of  the  membrane  without  any  chances  of 
[with  the  chances  against]  reparation,  and  loss,  or  at  least  ob- 
tundity  of  hearing,  are  the  inevitable  consequences,  when  the 
process  has  developed  to  a  certain  intensity.  The  influence 
upon  life  is  not  usually  disastrous.  The  fatal  issue,  when  it 
does  happen,  is  due  much  more  likely  to  diphtheritic  infection 
or  to  other  localizations  of  this  disease,  which  exist  at  the 
same  time,  than  to  otitis. 

Etiology. — Diphtheria  of  the  nasal  fossae  or  of  the  pharynx 
is  the  almost  essential  condition  of  diphtheritic  otitis.  While 
compatible  with  primary  diphtheria,  it  is  most  frequently  ob- 
served in  diphtheria  secondary  to  general  diseases  and  to  the 
exanthemata  such  as  measles,  scarlatina,  variola  and  typhoid, 
which  are  accompanied  by  active  inflammation,  on  the  part  of 
the  throat  and  nasal  fossae.  Of  these  diseases  scarlatina  is  the 
one,  the  influence  of  which  is  most  frequently  observed. 

Section  VII. — Diphtheria  of  the  Digestive  Tract. 

Next  to  angina,  the  most  common  of  the  localizations  of 
diphtheria,  not  only  on  the  digestive  tract,  but  on  all  the  or- 
gans of  the  economy,  should  be  enumerated  certain  less  fre- 
quent manifestations  on  other  portions  of  the  digestive  mucous 
membrane.  Nearly  all  being  accessible  to  view,  their  symp- 
tomatic description  differs  but  little  from  the  anatomical  de- 
scription. 

Diphtheria  of  the  Mouth. — The  mouth  is  often  the  seat  of 
diphtheritic  productions.  One  meets  with  them  on  the  lips, 
on  the  internal  surface  of  the  cheek,  and  on  the  tongue.  Since 
there  has  been  accorded  a  separate  existence  to  ulcero-mem- 


254  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

branous  stomatitis,  to  that  morbid  condition  which  Bretonneau 
confounded  with  diphtheria  under  the  name  of  fegarite  {can- 
criini  oris),  the  majority  of  authors  have  attributed  to  this  pro- 
cess all  the  pseudo-membranous  lesions  of  the  mouth.  Diph- 
theria of  the  mouth  does  not  find  its  place  in  the  works  which 
treat  of  stomatitis.  On  the  other  hand,  Trousseau,  while  ad- 
mitting the  ideas  of  Bergeron,  yet  gave  too  large  a  part  to 
diphtheria  ;  there  is,  therefore,  reason  for  conceding  to  the 
truth  its  place  between  these  two  extreme  opinions.  Diph- 
theria of  the  mouth  exists  beyond  question;  the  numerous  cases 
in  which  it  is  found  at  the  same  time  with  diphtheritic  angina 
proves  it  most  fully.  Hayem  has  published  an  extremely  in- 
teresting observation  showing,  in  addition  to  a  diphtheritic  an- 
gina, lesions  of  the  same  nature  largely  invading  the  mouth,  the 
tongue  and  the  lips.  These  cases  are  not  the  only  ones  ;  buc- 
cal diphtheria  is  not  always  a  simple  propagation  of 
angina,  it  is  frequently  independent  of  it.  The  false  membranes 
develop  by  preference  on  the  posterior  surface  of  the  lips,  the 
free  border,  the  commissures,  and  in  the  fold  between  the  lips 
and  gums.  The  lower  lip  is  most  frequently  attacked.  The 
internal  surface  of  the  cheeks,  the  palate,  the  alveolar  margin 
of  the  gums,  and  the  tongue,  either  on  its  edges,  on  the  dorsal 
surface,  near  the  point  or  on  the  sides  of  the  frenum,  are  less 
frequently  attacked.  Wherever  they  may  be  the  false  mem- 
branes are  yellowish-white,  round,  thin  at  the  edges,  thicker  in 
the  center,  adherent  in  the  beginning,  later  becoming  detached 
at  the  edges,  becoming  loosened  in  one  piece,  or  disappearing 
by  disintegration.  Their  structure  is  that  of  the  diphtheritic 
exudates.  The  mucous  membrane  nearly  always  remains 
sound.  At  the  commissures  these  membranes  assume  the  form 
of  a  border  which  follows  the  edge  of  the  lip,  or  a  patch  which 
is  projected  upon  the  integument  like  prolonging  the  cavity  ot 
the  mouth.  Upon  the  cheeks  its  form  is  the  same  as  upon  the 
lips.  Upon  the  tongue  they  are  in  patches  of  the  same  kind, 
more  extended  when  they  are  situated  on  its  edges.  In  certain 
cases  they  form  on  the  tip  a  cap  like  that  which  often  surrounds 
the  uvula.     When  the  lesions  are  very  extensive,  the  face  is 


LOCALIZATION    OF    DIPHTHERIA.  255 

swelled  about  the  parts  affected,  the  tissues  are  indurated,  pain- 
ful on  pressure,  and  often  oedematous.  The  mouth  is  opened 
with  difficulty,  particularly  when  the  commissures  are  attacked; 
the  movements  of  the  jaws  tear  the  mucous  membrane  and  make 
it  bleed.  When  the  tongue  is  implicated  it  becomes  two  or 
three  times  its  normal  size  and  protrudes  from  the  mouth. 
Rarely  the  margins  of  the  gums  are  attacked ;  they  do  not  al- 
ways escape  ;  they  ulcerate  and  leave  the  teeth  exposed.  Sali- 
vation is  profuse,  streaked  with  blood  and  often  contains  frag- 
ments of  pseudo-membrane.  Real  haemorrhage  may  occur 
from  the  buccal  mucous  membrane.  The  breath  exhales  a 
horribly  fetid  odor  which  extends  quite  a  distance,  but  which 
differs  entirely  from  that  of  gangrene.  The  sub-maxillary  lym- 
phatic ganglions  are  often  tumefied  as  well  as  the  surrounding 
connective  tissue.  During  the  first  few  days  the  impossibility 
of  opening  the  mouth,  and  the  swelling  of  the  tongue,  prevent 
the  examination  of  the  throat.  When  relaxation  occurs  one 
may  often  observe  the  existence  of  false  membranes  on  the  ton- 
sils, the  uvula,  and  the  pillars.  It  is  rarely  that  diphtheritic 
stomatitis  presents  a  like  intensity.  In  the  most  common  form 
the  lesions  are  limited  to  the  lips  ;  and  they  affect  the  tongue 
only  in  distinct  patches  of  limited  extent.  The  tumefaction, 
like  the  false  membrane,  is  then  confined  to  the  lips,  more  fre- 
quently to  the  inferior,  but  it  may  extend  to  both  at  once.  In 
this  case  the  lower  lip  is  attacked  first ;  the  swelling  of  the 
tongue  is  generally  quite  moderate.  More  rarely  still  patches 
develop  upon  the  internal  surface  of  the  cheeks  ;  they  coincide 
nearly  always  with  others  seated  upon  the  lips.  In  one  case, 
however,  they  occupied  this  position  exclusively.  After  ten  or 
twelve  days,  frequently  more,  the  false  membranes  separate 
and  fall  off,  leaving  the  mucous  membrane  healthy.  An  ex- 
ception must  be  made  of  those  on  the  tongue  which  erode  quite 
deeply  the  mucous  membrane  and  recover  by  leaving  a  cica- 
trix, as  Hayem  has  proved.  The  false  membranes  of  the  mouth 
have  not  the  tendency  to  invasion  of  those  of  the  skin  and 
other  mucous  membranes.  When  they  have  attained  dimen- 
sions approaching  that  of  a  dime  in  diameter,  they  remain  sta- 


256  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

tionary.  However,  they  sometimes  extend  from  one  lip  to  the 
other,  and  from  the  lips  to  the  cheeks.  From  the  standpoint 
of  general  symptoms  it  is  important  to  distinguish  buccal  diph- 
theria according  as  it  is  due  to  the  extension  of  diphtheritic 
angina  to  the  mouth,  or  as  it  is  isolated  and  secondary  to  a 
general  disease.  In  the  first  case  the  stomatitis  follows  the 
fortune  of  angina.  In  the  second  it  nearly  always  belongs  to 
infectious  or  malignant  diphtheria ;  and  it  is  accompanied  by 
grave  general  symptoms  and  by  pseudo-membranous  produc- 
tions at  different  points  of  the  economy,  to-wit,  on  the  skin,  the 
eyelids,  the  anus,  the  genital  organs, and  in  the  nasal  fossae. Croup 
and  pseudo-membranous  bronchitis  are  also  observed  at  the 
same  time  as  the  buccal  diphtheria  without  the  connecting  link 
of  angina.  Under  these  conditions  death  is  nearly  always  the 
result  of  diphtheritic  toxaemia.  Thus,  on  the  one  hand,  the 
false  membranes  that  are  met  with  in  these  two  categories  of 
cases  are  identical  as  pathological  products  ;  on  the  other,  they 
may  in  both  cases  accompany  the  symptoms  of  diphtheritic  in- 
fection even  when  they  have  only  a  trifling  importance  as  to 
the  local  conditions.  One  may,  therefore,  conclude  that  diph- 
theria, true  to  its  character  as  a  general  disease,  develops  itself 
upon  the  buccal  mucous  membrane,  as  well  as  upon  all  others, 
and  that  it  remains  independent  of  ulcero-membranous  stomati- 
tis from  which  the  most  decided  differences  separate  it.  While 
this  localization  of  diphtheria  is  often  a  consequence  of  angina, 
the  converse  is  rarely  true.  Trousseau  speaks  of  a  case  in 
which  angina  and  croup  were  occasioned  by  the  propagation  of 
buccal  diphtheria;  but  these  facts  are  exceptional.  The  dura- 
tion may  be  long.  If  one  may  believe  Trousseau,  it  may  even 
remain  stationary  for  several  months.  It  is  evident  that  the  il- 
lustrious observer  was  still  under  the  influence  of  the  ideas  of 
Bretonneau,  and  confounded  buccal  diphtheria  with  ulcero- 
membranous stomatitis.  I  have  never  seen  the  total  evolution 
exceed  fourteen  days  ;  in  cases  in  which  the  end  is  favorable, 
it  has  terminated  in  six  days.  When  the  diphtheritic  toxemia 
is  intense  death  occurs  in  three  or  four  days. 

Etiology. — What  precedes  gives  us  sufficient  instruction   on 


LOCALIZATION    OF    DIPHTHERIA.  257 

the  origin  of  diphtheritic  stomatitis.  It  is  primary  or  secondary. 
When  primary  it  is  most  frequently  one  of  the  accessories  of 
diphtheria  or  of  croup.  In  some  rare  cases  it  is  primary  and 
isolated.  When  it  constitutes  a  part  of  the  totality  of  angina 
or  of  croup,  one  frequently  observes  it  from  the  beginning,  or 
at  least  from  the  time  of  the  first  examination ;  when  one  sees 
it  arise  in  a  patient  observed  from  its  origin,  it  is  between  the 
third  and  the  eighth  day  that  it  usually  appears  ;  and  in  a  patient 
attacked  with  croup  without  angina  it  supervenes  the  four- 
teenth day.  When  secondary  it  appears  nearly  always  in  the 
train  of  measles.  In  thirty-three  cases  of  secondary  buccal  diph- 
theria, twenty-one  were  consecutive  to  measles,  three  to  whoop- 
ing-cough, three  to  scarlatina,  and  one  to  typhoid  fever,  the 
others  had  supervened  as  ultimate  phenomena  of  different 
cachexiae.  After  measles  it  begins  from  the  second  to  the 
eighteenth  day  of  the  eruption.  After  scarlet  fever  it  was  ac- 
companied by  angina ;  after  typhoid  fever  it  was  postponed 
three  weeks.  Cachectic  patients  suffered  for  a  period  vary- 
ing from  six  weeks  to  eight  months,  and  they  were  at  hospital 
from  ten  to  twenty-five  days. 

The  prognosis  varies  with  the  cause.  By  itself,  stomatitis 
has  no  gravity.  That  which  depends  upon  ah  angina  does  not 
aggravate  the  prognosis  of  the  latter.  That  which  is  secondary 
or  without  angina  follows  the  changes  of  generalized  infectious 
diphtheria.  The  false  membranes,  met  with  at  the  autopsy,  in 
the  oesophagus  and  stomach  seem  not  to  have  been  revealed 
by  the  symptoms  during  life.  The  dysphag-ia  and  the  digestive- 
disturbances  which  they  may  have  produced,  were  sufficiently 
explained  by  the  angina  which  accompanied  them.  The  same 
is  true  respecting  haematemesis  pointed  out  by  d'Espineand  by 
Greenhow ;  there  is  nothing  to  authorize  us  in  placing  them  to 
the  account  of  gastric  diphtheria.  The  cases  of  intestinal 
diphtheria,  pointed  out  by  Roche,  are  accompanied  by  symp- 
toms of  enteritis  and  discharge  of  false  membranes  per  anion^ 
Cases  of  this  kind  are  extremely  rare ;  one  may  always  sup- 
pose the  products  discharged  to  be  only  swallowed  false  mem- 
branes coming  from  the  throat.     He  must  await  othef  and  more 


258  DIPHTHERIA,  CROUP  AND  TRACHEOTOMY. 

conclusive  facts  before  pronouncing  a  decided  opinion  on  this 
question.  Anal  diphtheria,  pointed  out  by  d'Espine  who  re- 
garded it  as  coming  from  the  throat  by  successive  invasions,  is 
very  rarely  seen.  In  no  case  have  I  seen  evidence  of  pseudo- 
membranous propagation  by  contiguity  from  the  throat  to  the 
anus,  though  both  points  were  always  attacked  either  at  the 
same  time  or  the  one  after  the  other.  Croup,  cutaneous  diph- 
theria, and  that  of  the  genital  organs,  coincide  frequently  with 
that  of  the  anus.  The  commencement  occurs  at  the  circum- 
ference of  the  anus  in  the  radiating  folds  ;  the  false  membranes, 
at  first  limited,  sometimes  multiply,  enlarge,  unite  and  extend 
to  the  mucous  membrane  of  the  anus  which  swells  and  be- 
comes raw  and  bleeding.  Their  extension  is  outward  as  well ; 
and  reaches  the  perineum,  the  buttocks,  and  the  vulva;  but  it 
never  gives  rise  to  very  extensive  lesions.  If  death  does  not 
interrupt  its  course  anal  diphtheria  continues  from  six  or  eight 
days  to  a  month.  I  have  always  seen  it  attended  with  other 
diphtheritic  manifestations,  on  the  part  of  the  throat,  the  lar- 
ynx, or  other  organs.  Sometimes,  it  depends  upon  secondary 
diphtheria,  particularly  on  that  which  follows  scarlatina.  Not 
infrequently  it  is  the  extension  of  vulvar  diphtheria. 

The  prognosis  is  not  grave  when  we  consider  it  only  as  a 
local  lesion.  But,  first  of  all,  the  general  condition  must  be 
taken  into  account;  in  this  aspect,  the  appearence  of  oral  diph- 
theria always  indicates  a  certain  tendency  of  the  disease  to  be- 
come generalized.  The  gravity  depends  entirely  upon  the  de- 
gree of  toxaemia.  However,  the  mortality  is  not  high  ;  in  four 
cases  a  fatal  termination  occurred  in  only  one ;  still  this  was  a 
case  of  operated  croup.  The  patient  reported  ;by  Dr.  Espine 
succumbed  to  malignant  diphtheria. 

Section  VIII.— Diphtheria  of  the  Genital  Organs. 

Glans  and  prepuce. — Herard  has  published  two  observations 
of  diphtheria  of  the  glans  in  hemiplegics.  Trousseau  in  his 
clinical  medicine  reports  one  case  of  diphtheria  of  the  prepuce. 


I 


LOCALIZATION    OF    DIPHTHERIA.  259 

I  have  also  met  one  case.  It  is,  therefore,  one  of  the  rarest 
forms  of  diphtheritic  manifestations.  The  exudate  develops 
upon  the  preputial  mucous  membrane  or  on  that  of  the  glans, 
sometimes  upon  both.  When  it  occupies  the  glans  it  extends 
into  the  canal  of  the  urethra.  When  it  extends  on  the  pre- 
puce, this  becomes  swelled,  tense,  infiltrated,  and  red,  as  well 
as  a  portion  of  the  skin  of  the  penis.  The  glans  can  not  be 
exposed.  A  fetid,  serous,  liquid  escapes  from  the  opening  of 
the  prepuce.  Micturition  is  painful;  this  difficulty  extended  to 
retention  of  urine  in  the  case  which  I  observed.  The  inguinal 
glands  swell.  At  the  end  of  a  few  days,  when  the  tumefaction 
subsides,  the  glans  may  be  liberated  and  the  presence  of  false 
membranes  verified ;  they  are  white,  thin,  adherent,  with  irreg- 
ular margins,  and  without  gangrene  or  alterations  of  the  mu- 
cous membrane.  Diphtheria  of  the  throat,  nose,  larynx,  lips, 
etc.,  co-exist  with  that  of  the  penis.  It  appears  that  excoria- 
tions of  the  skin  or  of  the  mucous  membranes  serve  as  a  point 
of  departure  to  the  diphtheritic  exudate.  In  the  case  which  I 
have  cited,  recovery  was  effected  at  the  end  of  fourteen  days. 
From  a  local  point  of  view,  the  prognosis  is  not  alarming ; 
aside  from  the  retention  of  urine,  serious  symptoms  are  not  ob- 
served;  neither  ulceration,  nor  gangrene,  at  least  in  the  case  of 
which  I  speak.  The  general  condition,  however,  should  oc- 
casion reserve,  for  diphtheria  of  the  penis  constitutes  a  part  of 
the  forms  of  diphtheria  which  becomes  generalized. 

Vulva,  Vagina,  and  Uterus. — Trousseau,  Isambert,  Empis, 
and  Behier,  have  reported  diphtheria  of  these  organs  ;  the  vulva 
is,  of  those  parts,  the  most  frequently  attacked.  Violent  pain 
announces  the  outbreak,  afterwards  on  the  internal  surface  of 
the  labia  majora,  appear  small  pseudo-membranous  points 
which  extend,  unite,  and  form  veritable  diphtheritic  patches  ; 
the  labia  swell,  become  oedematous,  red  and  livid,  and  an 
abundant  discharge  appears  on  the  surface.  The  inguinal 
glands  become  enlarged.  The  exudate  may  remain  limited  to 
this  point.  Often,  however,  it  extends  to  the  labia  minora,  the 
vagina,  and  even  the  uterus ;  on  the  other  hand,  it  extends  on 
the  skin  towards  the  anus,  the  buttocks,  and  the  inguinal  region. 


260  DiniTIlERIA,   CROUP    AND    TRACHEOTOMY. 

Epidermic  elevations  filled  with  turbid  scrosity  arise  near  it. 
The  false  membranes  become  detached  at  the  end  of  a  period 
varying  from  a  week  to  a  month  ;  frequently  they  are  repro- 
duced. Recovery  takes  place  without  cicatrix,  unless  from 
complications  of  an  ulcerous,  or  gangrenous  nature, which,  how- 
ever, are  not  rare  in  vulvar  diphtheria,  particularly  when  it  is 
secondary.  The  influence  of  gangrene  is  especially  deleteri- 
ous ,  not  only  is  it  followed  by  loss  of  substance  quite  consid- 
erable, but  it  is  indicative  of  profound  toxaemia,  a  poisoning  of 
the  system,  the  consequence  of  which  is  death.  Diphtheria  of 
tbe  vagina  follows  that  of  the  vulva ;  by  separating  the  walls  of 
the  vagina  one  may  discover  the  pseudo-membranous  deposit. 
That  of  the  uterus  is  seldom  discovered  except  at  the  autposy  ; 
it  has  been  observed  in  women  during  confinement.  The  pla- 
cental attachment  furnishes  a  favorable  spot  for  the  develop- 
ment of  diphtheria.  We  may  entertain  suspicions,  when,  after 
a  vulvo-vaginal  diphtheria  which  supervened  in  a  recently  deliv- 
ered patient,  the  false  membranes  having  disappeared  from  their 
first  location,  we  see  the  general  symptoms  of  infectious  diph- 
theria persist  or  increase.  Vulvar  diphtheria  nearly  always  co- 
incides with  angina  and  croup.  It  may  be  isolated  as  a  diph- 
theritic manifestation ;  it  may  also  be  the  initial  phenomenon 
of  blood-poisoning.  In  one  of  the  cases  cited  by  Trousseau  it 
alone  showed  itself  in  a  woman  exposed  to  the  contagion  and 
who  died:  in  another  it  was  the  primary  symptom;  angina  fol- 
lowed in  the  course  of  a  few  days,  and  the  result  was  also  fatal. 
In  one  of  my  patients  it  was  limited  to  the  vulva  and  to  two 
small  diphtheritic  patches  on  one  of  the  inguinal  furrows;  one 
interesting  peculiarity  was  that  the  urine  contained  albumin. 
The  patient  recovered. 

Etiology. — Anal  diphtheria  is  either  primary  or  secondary. 
In  the  former  case  it  co-incides  with  angina,  or  also  with  pri- 
mary croup.  Ulceration,  herpetic,  eczematous  or  other  erup- 
tions, so  frequent  in  this  region,  invite  diphtheritic  localization. 
This  is  also  what  happens  when  diphtheria  commences  at  the 
vulva;  similar  accidents  serve  as  the  door  of  entrance,  starting 
point.     In  women  recently  confined,  the  contusion,  excoriation 


LOCALIZATION    OF    DIPHTHERIA.  26l 

of  the  genitals  by  the  passage  of  the  foetus  or  by  obstetrical 
manipulations  tend  greatly  to  favor  inoculation.  When  it  is 
secondary,  vulvar  diphtheria  belongs  particularly  to  scarlatina 
and  to  measles ;  it  then  assumes  more  readily  the  gangrenous 
form,  and  attains  to  the  greatest  gravity.  In  fact  it  is  nearly 
always  fatal.  Under  other  circumstances  the  prognosis  should 
be  based  upon  the  general  condition,  the  lesion  having  of  itself 
a  moderate  importance. 

Section  IX. — Cutaneous   Diphtheria. 

Though  pointed  out  by  Chomel  in  1749;  by  Starr  in  1750; 
and  by  Samuel  Bard  in  1771,  it  was  Trousseau  who  gave  prom- 
inence to  its  importance.  It  is  now  generally  admitted,  though 
certain  authors,  Billroth  among  them,still  confound  it  with  hospi- 
tal gangrene.  Every  point  of  the  skin  previously  inflamed,  or 
deprived  of  its  epidermis  may  become  its  seat.  This  is  why  we 
observe  it  as  a  sequence  of  blisters,  wounds,  excoriations,  fis- 
sures, after  eruptions  which  ulcerate  the  skin  as  herpes, eczema, 
and  impetigo.  It  readily  develops  in  the  folds  of  the  skin,  also 
where  the  latter  is  thin,  and  in  fleshy  subjects,  where  it  is  easily 
inflamed  or  excoriated :  such  are  the  folds  about  the  scrotum, 
the  anus,  the  umbilicus,  and  the  ears.  Such  also  are  the  ori- 
fice of  the  nose,  the  lips,  the  circumference  of  the  anus,  places 
where  the  skin  becomes  thin  and  upon  which  are  frequently 
found  eruptions.  The  scalp  is  one  of  the  places  of  election 
because  of  the  frequency  with  which  impetigo  prevails  there  ; 
the  same  is  true  also  with  the  nipple,  because  of  the  chaps  of 
which  it  is  the  seat.  The  parts  affected  become  red,  painful, 
bleeding,  and  form  an  ulceration  often  quite  large,  with  irregu- 
lar margins  cut  perpendicularly, which  sometimes  appear  on  the 
healthy  skin  as  lines,  which  Trousseau  compares  very  justly 
to  the  men  in  backgammon.  On  the  surface  are  deposited 
membranous  concretions  occupying  its  entire  extent  or  form- 
ing islets  separated  by  intervals  of  ulcerated  skin  ;  they  are 
thick,  convex  in  the  center,  thinner  at  the  borders,  of  a  light 
yellow  or  rather  grayish  color,  and  quite  adherent ;  often   they 


262  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

are  formed  of  several  stratified  layers.  It  is  easy  to  raise  them 
at  the  edges  by  means  of  forceps.  A  sero-purulent,  turbid, 
fetid,  fluid  transudes  abundantly,  and  softens  and  putrefies  the 
external  layers.  Around  the  ulcer  the  skin  is  inflamed,  swelled, 
and  erysipelatous.  The  elevation  which  it  forms  aids  in  mak- 
ing the  part  covered  with  the  false  membrane  appear  more 
excavated.  The  redness  and  the  tension  diminish  by  an  in- 
sensible gradation.  On  the  surface  of  this  zone  epidermic 
prominences  are  observed,  often  quite  numerous,  confluent,  and 
so  much  the  closer  together  as  they  approximate  the  ulcer.  A 
number  of  these  vesicles  often  unite  to  form  phlyctaense.  Their 
contents  are  turbid,  milky  and  serous.  When  they  are  broken 
or  when  they  become  withered,  the  base  is  seen  covered  with 
false  membrane  which  soon  becomes  united  to  the  main  one  or 
to  those  in  the  vicinity.  Other  epidermic  elevations  follow  the 
first  and  run  the  same  course.  In  this  way  propagation  is  ef- 
fected. In  certain  cases  gangrene  participates ;  the  false  mem- 
branes become  brown,  assume  the  characteristic  odor,  and, 
when  they  separate, debris  is  still  found  adhering  to  the  cleansed 
surface.  The  power  of  cutaneous  diphtheria  to  extend  is  often 
considerable ;  and  it  may  take  on  the  serpiginous  character. 
It  is  seen  to  embrace  the  back  from  the  shoulders  to  the  mid- 
dle of  the  loins.  Trousseau  remarked  that  it  usually  spread 
from  above  downward.  It  is  not  necessary,  however,  that  the 
local  condition  always  present  a  similar  intensity  ;  the  above 
description  answers  particularly  to  diphtheria  following  the  ap- 
plication of  a  blister ;  it  agrees  also  with  certain  cases  of  diph- 
theria of  the  scalp,  the  scrotum,  the  groin,  the  thighs  and  the 
buttocks;  but  most  frequently  this  condition  is  limited  to  ul- 
cerations of  small  or  medium  extent.  The  duration  depends 
upon  the  extent  of  the  false  membranes,  their  tendency  to 
spread,  the  cause  which  gives  them  origin  and  the  region  on 
which  they  develop.  But  when  they  are  consecutive  to  blisters, 
and  their  tendency  to  propagation  and  to  reproduction  is  very 
strong,  they  do  not  disappear  till  the  end  of  several  months. 
General  symptoms  exist,  not  only  when  cutaneous  diphtheria 
coincides  with  angina  or  croup,  but  also  when  it  prevails  alone. 


LOCALIZATION     OF     DIPHTHERIA.  263 

In  these  latter  cases  albuminuria  has  been  observed  several 
times,  as  well  as  diphtheritic  paralysis,  as  is  shown  by  the  cases 
cited  by  Roger,  Raciborsky,  Paterson,  Caspary,  Philippeaux, 
and  by  Gamier.  In  these  observations  we  see  paralysis  limited 
to  the  pharynx,  or  generalized,  following  diphtheria  developed 
at  the  groove  behind  the  ear,  at  the  umbilicus,  the  groin,  the 
surface  of  blisters,  traumatic  injuries,  and  cutaneous  eruptions, 
without  angina  having  existed.  Thus,  diphtheria  may  have  the 
skin  as  its  only  seat.  It  is  also  very  interesting  to  see  that  the 
external  tegument  may  be  the  first  point  invaded,  and  that  the 
throat  and  larynx  may  be  attacked  afterwards,  at  the  time,  or 
separately.  Of  this  I  have  observed  several  cases.  Trousseau 
cites  a  few  cases  of  it  in  his  Clinical  Medicine.  William  Mort- 
lake  reports  the  case  of  a  child  eight  years  old  who,  after  hav- 
ing been  attacked  with  diphtheria  around  the  umbilicus,  was 
seized,  in  spite  of  the  decided  amelioration  of  this  local  deter- 
mination, with  angina  and  croup  which  carried  it  off  Robert 
Bahrdt  relates  an  analogous  case  in  which  angina  and  croup  su- 
pervened two  days  after  a  diphtheria  which  had  developed 
upon  a  wound  ten  days  previously.  The  child  was  three  years 
old. 

Etiology. — Diphtheria  attacks  every  point  of  the  skin  in- 
flamed or  deprived  of  its  epidermis  by  ulceration  or  by  trau- 
matism. A  simple  injury  serves  as  a  place  of  entrance  (porte 
d'entree)  to  diphtheria  into  a  system  till  then  intact;  such  is 
the  case  of  Paterson's,  in  which  a  man,  while  yet  healthy,  put 
his  excoriated  finger  into  the  throat  of  his  child  affected  with 
diphtheritic  angina ;  the  finger  was  soon  attacked  with  diph- 
theria, which  remained  limited  to  that  point,  but  was  followed 
by  general  paralysis.  Trousseau  speaks  of  a  child  attacked 
with  cutaneous  diphtheria  arising  on  the  spot  of  an  excori- 
ation produced  on  the  thigh  by  the  rubbing  of  a  wheelbarrow, 
who  died  of  croup  as  a  consequence.  What  is  observed  in 
syphilis  and  in  other  virulent  diseases  occurs  in  these  cases : 
there  is  a  true  inoculation.  It  is  generally  admitted  that  the 
absence  of  the  epidermis  is  indispensable  to  the  development 
of  cutaneous  diphtheria.     It  may  be    so   when  the  person  is 


264  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

healthy  and  when  the  excoriation  serves  as  the  port  of  entry 
to  the  diphtheritic  poison.  When  the  patient  is  previously  in- 
fected it  often  happens  that  the  false  membrane  is  developed 
under  the  epidermis ;  the  exudation  is  produced  at  the  ex- 
pense of  the  corium  Malpighi  and  gives  rise  to  vesicles  or 
phlyctenae,  the  base  of  which  is  lined  with  false  membrane. 
In  these  cases  a  simple  irritation  of  the  skin  is  sufficient  to 
call  out  the  diphtheria.  Thus  it  shows  itself  on  places  at- 
tacked with  eczema,  impetigo  and  parts  affected  with  inter- 
trigo, about  wounds,  the  punctures  of  leeches  and  blisters.  I 
have  seen,  in  a  patient  attacked  with  croup,  a  paronychia  be- 
come the  starting  point  of  cutaneous  diphtheria;  in  another, 
an  old  burn  of  several  months  and  cicatrized  reopened  and 
became  covered  with  false  membranes;  in  a  third,  a  wound  of 
the  hand,  produced  by  a  fragment  of  glass,  had  the  same  ex- 
perience. These  examples  might  be  multiplied.  It  must  not 
be  supposed,  however,  that  under  the  circumstances  the  cuta- 
neous diphtheria  was  inevitable.  When  the  poisoning  is  very 
slight  it  happens  that  the  solutions  of  continuity  and  even  the 
surfaces  of  blisters  may  escape  diphtheria ;  this  I  have  been 
able  several  times  to  verify.  When  a  blister  is  about  to  be  at- 
tacked not  more  than  a  day  or  two  passes  before  the  false 
membranes  appear.  Excoriations  already  existing,  surfaces 
covered  with  impetigo  or  eczema  may  be  attacked  at  a  more 
distant  period.  A  burn,  above  spoken  of,  became  pseudo- 
membranous only  at  the  end  of  twenty-four  days  of  croup. 
Cutaneous  diphtheria  often  figures  in  secondary  diphtheria;  it 
is  then  attended  more  readily  with  gangrene. 

Prognosis. — Trousseau  regards  cutaneous  diphtheria  as  much 
more  serious  than  that  of  the  pharynx.  Literally  taken,  this 
conclusion  would  be  wanting  in  accuracy.  Indeed,  by  itself, 
this  local  manifestation  of  diphtheria  frequently  recovers.  I 
have  seen  cases  end  in  this  way  in  which  large  surfaces  had 
been  invaded.  Notwithstanding,  death  is  not  rare  from  ex- 
haustion which  results  from  the  very  free  suppuration.  On 
the  other  hand,  patients  are  seen  to  succumb  in  whom  cutane- 
ous diphtheria  occupied  but  a  limited  place   in  the   morbid  to- 


LOCALIZATION    OF    DIPHTHERIA.  265 

tality;  and,  as  in  all  the  other  manifestations  of  diphtheria,  its 
gravity  resides  in  the  degree  of  infection  which  it  represents. 
Left  to  itself,  and  without  any  other  localization,  it  may  be  at- 
tended by  alarming  general  symptoms  and  cause  death ;  the 
amount  of  poison  introduced  into  the  economy  becomes  rap- 
idly fatal  before  provoking  the  membranous  exudation  on 
other  points  ;  and  one  finds  himself  in  this  case  in  the  pres- 
ence of  malignant  diphtheria  with  unimportant  local  manifes- 
tations. Often  again,  when  it  is  alone,  it  is  the  expression  of  a 
benign  diphtheria  and  recovers.  Associated  with  other  local- 
izations it  becomes  the  index  of  the  generalization  of  diph- 
theria; and  it  is  only  one  of  the  elements  by  which  we  can  es- 
timate the  intensity  of  the  poisoning.  When  called  forth  by 
the  excessive  application  of  blisters  it  may  recover,  but  it  fre- 
quently renders  the  prognosis  less  favorable,  either  because  of 
the  suppuration  which  it  occasions,  or  because  of  the  stimulus 
it  seems  to  give  to  the  disease.  I  shall  cite  in  this  connection 
the  history  of  a  patient  attacked  with  mild  diphtheria  of  the 
nose,  which  simply  attracted  attention  and  was  recovering 
with  facility  when  some  one  had  the  unfortunate  notion  of  ap- 
plying a  blister  to  the  nape  of  the  neck  with  the  pretext  of 
hastening  the  cure.  This  issue  was  not  long  in  covering  itself 
with  false  membranes,  and  the  patient  died  in  a  state  of  maras- 
mus, without  any  considerable  extension  or  suppuration  hav- 
ing taken  place.  The  disease,  which  seemed  dormant,  was 
aroused  under  the  influence  of  the  cutaneous  irritation. 

Course,  Duration,  Termination. 

In  passing,  I  have  already  indicated,  in  each  of  its  forms  and 
localities,  the  course  which  diphtheria  takes.  This  disease  is 
always  portrayed  by  one  or  several  local  expressions.  How- 
ever slight  they  may  be,  should  they  be  weakened  to  the  point 
of  not  being  pseudo-membranous,  these  local  determinations 
sufficiently  so  modify  the  course  of  the  principal  disease  that 
the  reciprocal  action  of  these  two  elements  exhibits  peculiar 
combinations.  While  preserving  the  impress  of  the  general 
disease,  each  combination  possesses  peculiar  properties  which 


266  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

make  it  act  differently  from  another  in  which  a  different  local 
condition  enters. 

Thus,  in  describing  the  course  of  these  local  manifestations, 
a  course  which  is  itself  influenced  by  the  form  of  the  diphthe- 
ria, I  have  shown  in  that  way  the  course  of  this  disease.  It  is, 
therefore,  necessary  to  refer  to  each  of  those  chapters.  There 
is  another  point  to  which  I  desire  to  return,  that  is  the  order 
in  which  these  localizations  follow. 

Brettonneau,  and  Trousseau  after  him,  assigned  to  the 
propagation  an  order  in  some  sense  invariable.  The  pro- 
gression is  regularly  made  from  the  superior  towards  the  in- 
ferior parts,  from  the  nasal  fossae  to  the  pharynx,  from  the 
pharynx  to  the  larynx,  then  to  the  bronchi.  Likewise,  when 
the  diphtheria  attacks  the  skin,  the  extension  is  made  also  to- 
wards the  dependent  parts :  from  the  ears  towards  the  neck 
and  back,  and  from  the  back  towards  the  loins.  The  cele- 
brated physician  of  Tours  regarded  diphtheritic  contagion  as  a 
kind  of  auto-inoculation  produced  by  an  acrid  liquid  which 
secreted  by  the  diseased  surfaces,  would  contaminate  success- 
ively the  more  dependent  parts.  This  order,  which  was  evi- 
dent in  the  epidemics  of  Touraine  observed  by  Bretonneau, 
has  numerous  exceptions.  Some  observers,  such  as  Boudet,Vau- 
thier,  Rilliet,  Barthez,  Isambert,  Newcourt,  Axenfeld,  Empis, 
Millard,  Crequy,  Bouillon,  Lagrange,  Bergeron,  Blondeau, 
Hache,  etc.,  have  reported  such. 

As  pertinent  to  the  origin  of  croup,  I  have  proved  that  an- 
gina and  coryza  do  not  always  precede  croup,  but  that  in 
quite  an  important  number  of  cases,  in  one-half,  according  to 
Rilliet,  one-third  according  to  Bergeron,  and  one  in  twenty 
according  to  J.  Simon,  and  by  my  figures  in  one  in  eight  cases, 
croup  appears  before  the  angina.  We  have  also  seen  pseudo- 
membranous bronchitis  precede  croup. 

Other  facts  no  less  interesting  have  been  revealed  to  me 
during  the  examination  of  the  various  local  manifestations.  I 
have  showed  that  cutaneous  diphtheria  may,  in  spreading, 
ascend,  in  place  of  descending.  I  have  pointed  out  the  ex- 
tension of  the  false  membrane  from  the  nose  to  the  eye  by  the 


LOCALIZATION    OF    DIPHTHERIA  26/ 

nasal  duct,  and  from  the  pharynx  to  the  ear  by  the  Eustachian 
tube.  Still  more,  I  have  indicated  the  coexistence  of  diphthe- 
ritic localizations  having  between  them  not  a  trace  of  conti- 
guity, viz.,  angina  or  croup  with  cutaneous  diphtheria,  or  with 
that  of  the  genital  organs,  and  vice  versa ;  the  diphtheria  ot 
the  lips,  skin  and  genital  organs  accompanying,  together  or 
separately,  angina  or  croup,  and  finally  developing  separately 
or  combinedly,  without  pharangeal  or  laryngeal  manifestations. 
The  consequence  of  these  exceptions  is  that  the  law  im- 
posed by  Bretonneau  should  be  annulled  so  far  as  its  being  an 
absolute  rule  is  concerned.  In  the  cases  in  which  it  is  the 
least  affected,  in  the  relation  of  angina  with  croup,  it  is  sub- 
ject to  numerous  infractions.  Facts  such  as  Bretonneau  ob- 
served suggested  to  him  the  famous  theory  according  to  which 
diphtheria,  at  first  localized  at  its  point  of  entrance  into  the 
economy,  like  syphilis  when  it  is  still  only  represented  by  the 
chancre,  is  expanded  afterwards,  from  step  to  step,  to  the  in- 
fecting of  the  whole  organism.  The  different  epidemics,  and 
new  facts  observed  since  that  time,  have  enabled  us  to  recog- 
nize wherein  this  view,  so  specious,  was  arbitrary.  The  ap- 
pearance, often  simultaneous  and  most  frequently  without  in- 
tervention of  diphtheritic  productions  upon  points  the  most 
diverse  of  mucous  and  of  cutaneous  surfaces,  has  furnished  a 
powerful  argument  for  the  theory  which  I  shall  at  a  later  pe- 
riod establish,  a  theory  which  holds  that  diphtheria,  like  all 
infectious  diseases,  contaminates  primarily  (d'emblee)  the  en- 
tire economy,  and  that  from  this  intoxication  result  the  most 
varied  pseudo-membranous  localizations  and  visceral  lesions  of 
the  most  general  character. 

Recedives — Second  Attacks. 

One  attack  of  diphtheria  does  not  protect  from  a  second. 
This  disease  may  attack  a  second  time — recedive.  I  find  in 
my  observations  twenty-nine  cases  of  second  attacks  of  diph- 
theria, without  counting  those  spoken  of  by  Gambault,  Mil- 
lard, Roger  and  Peter.  The  interval  which  separates  the  two 
attacks  of  diphtheria  varies  from  a  few  days  to  several  years. 


268 


DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 


It  was,  counting  from  the  recovery  of  the  first : 


2  days  in 

3  " 

4  " 

5  " 

6  " 

7  " 


I      lO  days  in 


2 

II 

(< 

3 

15 

<( 

3 

19 

<( 

I 

20 

(( 

3 

I 

> 

ear 

I 

12 

a 

2 

I 

I 

2 
2 
2 
I 

29 


Total,      -------- 

I  have  seen  one  patient  in  whom  there  was  a  double  recedive. 
The  second  occurred  some  days  after  the  recovery  from  the 
first  recedive.  The  reproduction  often  affects  the  same  place, 
but  it  does  occur  that  the  second  attack  affects  a  different  lo- 
cation. When  the  first  attack  consisted  in  an  angina  the  sec- 
ond was  generally  also  an  angina.  In  case  of  a  previous 
croup  angina  alone  may  be  reproduced,  however,  I  have  seen 
several  cases  of  second  attacks  of  croup.  Those  that  I  have 
seen  did  not  lead  again  to  the  operation ;  the  angina  alone,  or 
croup  not  very  serious,  reappeared.  It  does  not  always  hap- 
pen thus,  as  well-known  observations  of  tracheotomy  prac- 
ticed twice  on  the  same  subject  for  croup  clearly  prove. 

The  second  attacks  occur  without  apparent  cause;  they  are 
often  determined  by  eruptive  fevers,  measles  or  scarlatina. 
Their  gravity  has  nearly  always  been  less  than  that  of  the  first 
attack ;  in  twenty-nine  cases  of  recedive,  twenty-two  termi- 
nated favorably.  The  double  recedive  gave  a  third  recovery. 
It  has  appeared  that  in  many  of  these  cases  the  diphtheria,  in 
being  repeated,  lost  its  gravity. 

Diagnosis. 

The  presence,  in  parts  open  to  inspection,  of  large  false 
membranes  exhibiting  the  characteristics  of  the  diphtheritic 
exudate  ;  the  development  of  extensive  adenitis  in  their  vicinity, 
and  in  the  submaxillary  region  in  particular  ;  together  with  the 
establishment  of  special  general  symptoms,  warrant  us  in  af- 
firming without  hesitation  that  diphtheria    exists.     But    certain 


LOCALIZATON    OF    DIPHTHERIA.  269 

circumstances  give  rise  to  difficulties.  The  age  of  the  patient 
is  an  important  one.  An  adult  and  a  good  sized  child  will  ex- 
press their  feelings,  and  will  call  the  physician's  attention  to  the 
region  where  they  feel  pain.  It  is  quite  otherwise  with  a  little 
child;  an  examination  of  every  function  and  of  every  organ  is 
indispensable  in  the  absence  of  information  furnished  by  the 
patient.  A  diphtheritic  pharyngitis  existing  under  these  con- 
ditions, which  is  not  a  rare  case,  and  deglutition  being  moder- 
ately painful  and  and  adenitis  being  wanting,  the  disease  runs 
a  risk  of  being  unrecognized.  The  precept  laid  down  by 
Trousseau  should  then  be  observed  strictly,  that  whenever  a 
little  child  is  sick  for  several  days  and  the  morbid  condition  re- 
mains ill-characterized,  the  physician  should  examine  the 
fauces.  He  will  then  very  often  discover  a  diphtheritic  phar- 
yngitis, whose  existence  not  a  single  special  symptom  had  giv- 
en him  reason  to  suspect.  I  shall  be  still  more  radical.  The 
fauces  should  be  inspected  in  every  child,  at  least  where  there 
are  not  found  at  once  unmistakable  symptoms  of  a  definite  dis- 
ease. Still  it  is  prudent,  in  hospitals  especially,  and  in  an  en- 
vironment where  diphtheria  holds  sway,  to  often  ascertain  the 
condition  of  that  region,  not  only  at  the  beginning,  but  during 
the  course  of  every  disease.  Allowing  cases  of  secondary  diph- 
theria to  pass  unnoticed,  will  thus  be  avoided. 

This  sort  of  complication  ought,  in  fact,  to  keep  the  attention 
aroused.  Everything  conduces  to  overlooking  it.  If  it  be  a 
matter  of  exanthems,  such  as  measles  or  scarlatina,  which  no- 
toriously favor  the  development  of  diphtheria,  the  observer 
should  be  on  his  guard,  and  error  will  be  relatively  uncommon. 
But  if  it  be  a  question  of  typhoid  fever,  a  disease  which  is  often 
accompanied  not  only  by  difficulty  of  deglutition, by  dryness  of 
the  fauces  or  by  a  sjDecial  pharyngitis,  but  by  stupor,  and  by 
coma  deep  enough  to  veil  the  manifestations  of  diphtheria  ; 
when  diseases  like  pleurisy,  pneumonia  or  capillary  bronchitis, 
in  which  oppressed  breathing  is  one  of  the  symptoms,  are  to  be 
dealt  with,  or  cachexias  such  as  scrofula,  chronic  diarrhoea  or 
tuberculosis  which  bring  in  their  train  the  most  varied  func- 
tional troubles,  such  an    omission  is  possible   and  is  not  rare. 


2/0  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

On  the  other  hand,  we  may  see  the  severest  diphtheria  give 
rise  to  barely  a  few  general  symptoms,  allowing  the  patients  to 
go  and  come,  and  preserve  almost  intact  their  habitual  modus 
vivendi.  The  autopsy  alone  often  reveals  these  secondary 
diphtherias. 

The  feeble  intensity  of  the  group  of  symptoms  is  perhaps 
the  most  serious  difficulty  to  be  met  with  in  the  diagnosis  of 
diphtheria. 

The  slight  importance  of  the  lesions,  and  the  absence  of 
apparcjit  infection  have  led  to  the  separation  from  this  disease, 
under  the  names  of  herpetic  or  diphtheroid  pharyngitis,  of 
morbid  conditions  W'hich  were  really  only  benign  forms.  Not 
that  I  would  deny  the  existence  of  herpes  of  the  fauces,  for  I 
shall  develop  later,  the  characteristics  which  distinguish  it  from 
diphtheritic  pharyngitis.  I  only  maintain  that  cases  of  diph- 
theria where  the  localization  has  been  discrete  and  made  up  of 
isolated  points,  have  been  mistaken  for  herpetic  pharyngitis. 
At  its  beginning  diphtheria  assumes,  in  fact,  the  most  various 
local  dispositions,  from  a  pseudo-membranous  patch  carpeting 
the  whole  of  the  fauces,  to  isolated  points  like  those  of  herpetic 
pharyngitis.  How  often  have  we  seen  these  so-called  cases  of 
herpetic  pharyngitis  end  in  croup,  or  in  a  generalization  of 
diphtheria.  How  many  examples  they  have  exhibited  of  cases 
originating  by  contagion  from  the  most  fully  marked  cases  of 
diphtheritic  pharyngitis  or  on  the  other  hand  transmitting, 
though  they  themselves  are  benign,  the  most  serious  manifes- 
tations of  diphtheria.  The  facts  reported  by  Guerard  and  by 
Peter  are  most  conclusive  upon  this  point. 

The  coexistence  of  Jierpes  labialis  does  not  suffice  to  invest 
the  pharyngitis  with  an  herpetic  character.  Like  Peter,  I  have 
seen  the  gravest  diphtheria,  coexisting  with  patches  of  herpes 
upon  the  lips,  and  I  have  met  cases  of  so-called  herpetic 
pharyngitis,  accompanied  by  albuminuria  and  followed  by  pa- 
ralysis. 

The  color  and  thickness  of  the  false  membrane  do  not  give 
any  more  instructive  information ;  for  those  which  are  white, 
thin  and  semi-transparent,  are  as  justly  diphtheritic   as  those 


LOCALIZATION     OF    DIPHTHERIA.  2/1 

which  are  thick,  opaque,  and  dark  gray   or  brown.     An    ener 
getic  inflammatory  reaction,  and  a  lively  redness  of  the  mucous 
membrane,  prove  no  less  in  favor  of  diphtheria  than   a  torpid 
course  without  reaction. 

The  objective  characteristics  are  then  not  sufficient  to  set  the 
question  at  rest.  Never  do  they  authorize  the  exclusion 
of  the  idea  of  diphtheria,  but  they  often  warrant  its  admis- 
sion. 

The  general  symptoms,  information  as  to  etiology,  and  above 
all,  the  later  course  of  the  disease  are  necessary  to  settle  the 
diagnosis.  We  may  then  lay  it  down  as  a  principle,  that,  in 
a  certain  number  of  cases  the  diagnosis  of  diphtheria  cannot  be 
made  from  the  beginning,  and  that  only  the  course  of  the  disease 
will  enable  us  to  Judge  imderstandingly:  also,  that  from  the 
beginning  of  an  affection  suspected  to  be  pseudo-membranous, 
we  should  act  as  far  as  concerns  the  isolation  of  the  patient, 
as  though  we  were  dealing  with  a  veritable  case  of   diphtheria. 

If  the  disease  is  benign,  and  of  slight  extent,  the  diagnosis  is 
still  more  difficult;  for  the  aggravation  later  on  no  longer  fur- 
nishes the  information  which  is  above  given.  Then  it  is,  that 
the  albuminuria,the  adenitis  and  in  default  of  these  the  etiolog- 
ical circumstances  are  of  valuable  aid.  Light  pseudo-mem- 
branous manifestations  appearing  in  an  environment  where 
diphtheria  is  raging,  should  be  accredited  to  that  disease.  I 
will  develop  that  question  more  fully  when  I  treat  of  the  natme 
of  diphtheria. 

Such  are  the  difficulties  which  complicate  the  diagnosis  of 
diphtheria.  We  shall  find  them  again  in  most  of  the  localiza- 
tions of  this  disease,  augmented  by  the  confusion  which  might 
arise  between  those  localizations  and  different  lesions  occupy- 
ing the  same  regions.  We  must  needs,  then,  establish  the  to- 
pographical diagnosis  of  diphtheria  and  distinguish  its  local 
manifestations  from  the  morbid  conditions  which,  when  they 
attack  the  fauces,  the  air-passages  and  other  organs,  might  be 
mistaken  for  the  former.  I  shall  reproduce  in  discussing  the 
diagnosis,  the  order  which  I  adopted  in  detailing  the  symp- 
toms. 


2/2  DIPHTHERIA,    CKOUP  AND    TRACHEOTOMY. 

Since  diphtheria,  aside  from  entirely  exceptional  cases,  is  a 
disease  with  a  course  essentially  acute.  I  shall  only  have  to 
discriminate  its  localizations  from  the  acute  affections  of  the 
same  regions. 

Pharyngeal  Diphtheria. 

It  is  particularly  with  regard  to  diphtheritic  pharyngitis  that 
the  diagnosis  is  likely  to  be  difficult.  The  pharyngitis  which 
presents  itself  with  large,  thick,  dark  gray,  pseudo-mem- 
branous patches,  with  single  or  double  sub-maxillary  swelling, 
with  coryza  and  the  characteristic  odor,  leaves  no  ground  for 
doubt :  the  diagnosis  is  self-evident.  Those  forms  of  attenu- 
ate pharyngitis,  those  in  which  the  product  is  like  the  exudate, 
those  also  which  give  rise  to  a  real  exudate,  but  not  a  diph- 
theritic one,  should  be  scrupulously  differentiated  from  diph- 
theria. Before  entering  upon  the  differential  characteristics,  I 
must  again  insist  upon  the  difficulty  of  diagnosticating  diph- 
theria at  the  beginning.  The  distinctive  signs  which  I  am 
about  to  detail  are  rarely  clear  enough  at  this  period  to  war- 
rant the  formation  of  a  positive  diagnosis.  This  pharyngitis 
has  no  peculiar  mode  of  attack,  but  begins  in  several  very  dif- 
ferent ways  as  regards  general  symptoms  as  well  as  from  the 
standpoint  of  local  signs.  The  physician  should  also  be  im- 
bued with  the  precept  that  every  pharyngitis,  wlietlier  acco7n- 
panied  or  not  by  an  exudative  product  or  the  like,  however 
discrete  or  benign  it  may  appear,  should  be  regarded  with  sus- 
picion, and  held  under  observation  for  several  days  before  a 
diagnosis  can  be  legitimately  made. 

The  kinds  of  pharyngitis,  the  product  of  which  resembles 
the  exudate,  are  :  follicular  tonsillitis  with  exaggerated  pro- 
duction of  sebum.,  piiltaceons  pharyngitis,  pJiaryngitis'of  scarla- 
tifia,  gangrenous  pharyngitis  and  ulcero-inenibranoiis  pharyn- 
gitis. One  kind  only  presents  a  true  exudate,  viz.,  herpetic 
pharyngitis. 

These  inflammations  of  the  fauces  do  not  present  points  of 
semblance  to  diphtheritic  pharyngitis  except  in  its  benign 
form,  or  at  its  beginning;  gangrenous  pharyngitis  alone  being 
likely   to  be   confounded  with  severe  diphtheritic  pharyngitis. 


LOCALIZATION     OF     DIPHTHERIA.  2/3 

Follicular  Tonsillitis. — This  form  of  pharyngitis  is  character- 
ized by  an  exaggerated  production  of  the  sebaceous  material 
of  the  crypts  of  the  tonsils.  Usually  insignificant  as  to  gen- 
eral or  functional  symptoms,  it  shows  only  a  slight  redness  of 
the  mucous  membrane.  Masses  of  white  material  push  out 
from  the  follicles,  forming  upon  the  surface  of  the  gland  white 
spots  which  show  a  certain  resemblance  to  false  membranes  in 
process  of  formation.  But  on  close  examination  these  spots 
appear  much  more  salient  than  false  membranes.  From  the 
first  they  are  thick  and  salient,  while  the  false  membrane  is 
thin  and  pellucid  at  the  beginning.  Often  the  orifice  of  the 
follicle  from  which  the  concretion  is  projecting  can  be  recog- 
nized. The  latter  is  almost  always  single,  and,  when  there  are 
several,  they  are  distant  from  one  another,  and  show  no  ten- 
dency to  unite.  There  is  no  submaxillary  swelling.  Finally, 
scraping  the  tonsil  with  a  spatula,  immediately  detaches  the 
suspected  product  and  brings  out  a  cheesy  mass  with  a  foetid 
odor  which  crushes  under  the  finger,  and  is  at  once  recognized 
as  sebaceous  material. 

Pultaceoiis  Pharyngitis. — Though  sometimes  coincident  with 
a  simple  catarrhal  condition  of  the  faucal  mucous  membrane, 
pultaceous  pharyngitis  is  much  oftener,  according  to  Trous- 
seau's expression,  cited  by  Peter,  the  pharyngitis  of  low  gen- 
eral conditions,  the  pharyngitis  of  the  feeble  and  the  old,  that 
of  scarlatina  and  of  typhoid  fever.  It  is  accompanied  by  a 
febrile  movement,  usually  slight,  and  by  a  certain  saburral 
condition.  But  that  which  constitutes  its  important  point 
with  regard  to  its  diagnosis  from  diphtheritic  pharyngitis,  is  the 
presence  of  false  membranes  of  a  very  special  character. 
These  productions  form  large  patches  of  a  creamy  white, 
which  almost  always  occupy  the  tonsils,  more  rarely  the  pil- 
lars. They  have  no  tendency  to  spread,  and  when  once  pro- 
duced they  enlarge  but  little.  They  are  thin,  and  permit  the 
mucous  membrane  to  be  seen  through  them,  if  not  every- 
where, at  least  at  several  points.  They  are  soft,  falling  to 
pieces  simply  by  rubbing  with  a  brush  or  a  sponge,  and  com- 
ing away  in  fragments  without  leaving  a  single  visible  altera- 


2/4  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

tion  of  the  mucous  membrane  and  without  the  slightest  haem- 
orrhage being  brought  on  by  the  operation. 

The  special  characteristic  of  these  false  membranes  is  their 
structure.  As  Peter  has  demonstrated,  it  is  epithelial  simply. 
In  it  the  microscope  has  discovered  only  pavement  cells,  en- 
tire or  altered,  together  with  nuclei  and  nucleoli  and  rem- 
nants of  cells  and  of  broken  up  nuclei.  Neither  fibrils  nor 
amorphous  material  nor  anything,  has  been  met  with,  which 
indicates  the  existence  of  fibrin  in  its  different  forms.  Stripped 
of  these  products  the  mucous  membrane  remains  red,  smooth 
and  covered  with  a  recent  and  delicate  epithelium. 

The  results  contributed  by  histology  are  of  great  impor- 
tance. However  different,  in  fact,  pultaceous  pharyngitis  may 
be  from  diphtheritic  pharyngitis  in  its  course,  in  the  absence 
of  adenitis  and  in  the  appearance  of  the  false  membranes, 
there  is  still  ground  for  mistake.  Diphtheria  at  its  beginning 
too  often  furnishes  false  membranes  which  are  similar  in  gen- 
eral appearance.  But  the  excessive  friability  of  the  pultaceous 
product  will  always  allow  fragments  of  it  to  be  detached, 
which,  placed  on  the  stage  of  the  microscope,  will  at  once 
clear  up  the  diagnosis. 

Scarlatinous  Pharyngitis. — In  the  same  class  with  pultaceous 
pharyngitis  it  is  well  to  place  the  pharyngitis  of  scarlatina,  the 
product  of  which  is  the  same,  but  which,  by  the  fact  of  its 
origin,  is  accompanied  by  special  symptoms.  The  frequency 
with  which  scarlatina  is  followed  by  true  diphtheria  renders 
the  diagnosis  between  simple  scarlatinous  sore  throat  and 
diphtheritic  sore  throat  one  of  great  importance.  The  pharyn- 
gitis in  question  is  not  rare.  It  is  an  exaggeration  of  the  in- 
flammation which  scarlatina  necessarily  produces  in  the  fauces. 
It  is  oftenest  limited  to  an  intense  congestion  of  the  mucous 
membrane,  a  congestion  like  that  which  appears  upon  the 
skin.  But  when  the  eruption  is  violent  desquamation  of  the 
epithelium  occurs,  whence  comes  a  production  of  pultaceous, 
white  patches. 

The  characteristics  of  scarlatinous  pharyngitis  have  been 
clearly  indicated  by  Trousseau,   Barthez  and  Rilliet,  and  by 


LOCALIZATION    OF    DIPHTHERLV.  2/5 

Peter.  The  rapidity  of  its  appearance,  the  almost  sudden  in- 
tensity of  the  febrile  movement,  and  the  existence  of  an 
eruption  upon  the  faucal  mucous  membrane  like  that  upon  the 
skin,  only  darker,  permit  the  scarlatinous  nature  of  the  diph- 
theria to  be  established.  But  this  is  not  enough  in  the  case. 
We  must  distinguish  between  the  two  affections  produced  by 
scarlatina ;  in  other  words,  must  find  out  whether  the  scarla- 
tinous pharyngitis  is  pultaceous  or  diphtheritic.  The  diag- 
nosis is  so  much  the  more  difficult  because  scarlatina  is  very 
often  accompanied  by  glandular  swelling,  and  we  are  de- 
prived of  one  of  the  best  means  of  differentiating  diphtheria 
from  other  diseases. 

The  pultaceous  appearance  of  the  patches,  such  as  I  have 
described  in  the  preceding  chapter,  usually  suffices  to  show 
that  the  pharyngitis  is  not  of  a  diphtheritic  nature.  But  since, 
in  this  case  as  in  every  other,  the  products  of  diphtheria  may 
assume  at  first  a  pultaceous  appearance,  microscopic  examina- 
tion will  be  necessary,  otherwise  the  course  of  the  disease  only 
can  clear  up  the  diagnosis.  The  distinction  which  I  make 
between  the  pharyngitis  of  scarlatina  and  that  of  diphtheria 
has  not  been  always  admitted.  The  diphtheria  that  follows 
scarlatina,  even  when  generalized,  was  considered  as  a  pharyn- 
gitis secondary  to  scarlatina,  a  pharyngitis  the  product  of 
which  might  invade  the  whole  economy,  but  which  was  inde- 
pendent of  diphtheria.  Peter,  supporting  his  very  clear  judg- 
ment by  the  authority  of  Trousseau  and  that  of  Barthez,  sepa- 
rates scarlatinous  pharyngitis,  properly  so  called,  from  diph- 
theritic pharyngitis  secondary  to  scarlatina.  I  indorse  without 
hesitation  the  opinion  of  these  eminent  physicians.  Every- 
thing, in  fact,  separates  these  two  forms  of  pharyngitis,  which 
have  in  common  only  a  white  product  situated  in  the  fauces. 
But  without  reckoning  that  this  product  is  absolutely  different 
in  the  two  cases,  its  structure  being  exclusively  epithelial  in 
the  one  case  and  fibrinous  in  the  other,  how  dissimilar  are  the 
characteristics  of  these  two  processes !  Who  has  ever  proved 
that  this  epithelial  desquamation,  following  scarlatina,  had  the 
power  of  becoming  general,  of  attacking  the  nasal  fossae,  the 


2/6  DIPHTHERIA,  CROUP    AND    TRACHEOTOMY. 

larynx  and  the  bronchi?  Is  not  this,  on  the  contrary,  the 
course  so  peculiar  to  diphtheria? 

Finding  in  scarlatina,  as  in  measles  and  typhoid  fever,  a  soil 
ready  prepared,  diphtheria  there  develops,  but  takes  the  site 
which  the  scarlatina  itself  offers,  that  is  to  say,  its  first  mani- 
festation always  appears  in  the  fauces,  the  point  where  scarla- 
tina produces  its  most  intense  inflammation.  Rarely  does  it 
go  beyond  that  limit,  but  if  it  appear  in  other  regions,  it  is 
usually  after  it  has  affected  the  fauces.  Once  developed  in  the 
pharynx,  the  diphtheria  may  migrate  to  any  other  part,  and  al- 
though, indeed,  the  celebrated  proposition  of  Trousseau  al- 
ways obtains,  viz.,  that  "  Scarlatina  has  no  love  for  the  laryjix," 
it  is  none  the  less  true  that  the  organ  may  be  attacked  ;  but  in 
the  great  majority  of  cases  it  is  by  an  extension  of  the  process 
which  began  in  the  fauces. 

The  presence  of  albuminuria  also  separates  these  two  kinds 
of  pharyngitis.  Though,  in  fact,  we  can  recognize  in  the  two 
cases,  the  presence  of  albumen  in  the  urine,  it  is  found  in  each 
of  them  at  quite  different  stages. 

In  diphtheria  it  is  quite  frequent  near  the  beginning;  in  scar- 
latina it  is  found  much  more  rarely,  and  only  during  the  per- 
iod of  desquamation  and  at  a  time  when  the  pharyngitis  has, 
moreover,  usually  disappeared. 

Pharyngitis  oj  Typhoid  Fever. — Like  scarlatina,  typhoid  fever 
engenders  erythematous  or  pultaceous  sore  throats.  The  lat- 
ter species,  the  one  which  alone  interests  us,  has  of  itself  but 
slight  importance  and  for  that  very  reason  we  must  avoid  con- 
founding it  with  diphtheritic  pharyngitis  secondary  to  typhoid 
fever.  The  latter  has  especially  pre-occupied  authors,  and 
many  cases  of  it  are  cited  by  Louis,  Herard,  Oulmont,  and 
Chedevergne.  In  his  interesting  work  on  pharyngitis  following 
typhoid  fever,  Chedevergne  shows  too  great  a  tendency  to  con- 
found these  two  kinds  of  pharyngitis.  Peter,  on  the  contrary, 
distinguishes  them  with  care. 

The  pultaceous  pharyngitis  of  typhoid  fever  is  of  the  same 
nature  as  that  of  scarlet  fever.  It  is  formed  like  the  latter,  by 
a  desquamation  of  the  epithelium  of  the  mucous  membrane. 
The  characteristics  of  the  product  are  identical. 


LOCALIZATION    OF    DIPHTHERIA.  2// 

According  to  the  happy  expression  of  Peter,  pultaceous 
pharyngitis  is  to  the  isthmus  of  the  fauces  what  the  whitish  bor- 
der of  the  gums  is  to  the  mouth. 

The  mucous  membrane  is  red,  dry,  and  as  though  varnished, 
submaxiUary  engorgement  is  always  absent.  In  short,  this 
sore  throat  would  be  overlooked  if  the  patient  did  not  some- 
times complain  of  the  fauces,  and  if  care  were  not  taken  to  fre- 
quently inspect  this  same  region.  The  extreme  friability  of 
these  products,  which  are  always  easily  removed  by  a  tongue 
depressor,  and  finally  the  microscopic  examination  permit 
them  always  to  be  recognized. 

Gangrenous  Pharyngitis. — For  a  long  time  confounded  with 
diphtheritic  pharyngitis,  gangrene  of  the  fauces,  was  separated 
by  Samuel  Bard  and  afterwards  by  Bretonneau  who, going  to  the 
opposite  extreme,  denied  it  absolutely.  In  rendering  to  each 
his  due,  the  works  of  De  la  Berge,  and  Monneret,  Becquerel, 
Rillietand  Barthez,  Gubler,  Trousseau,  Peter,  and  others,  should 
be  mentioned. 

Great  difficulties  often  complicate  the  diagnosis.  If  gangren- 
ous pharyngitis  is  sometimes  a  primary  affection,  it  is  still  more 
often  secondary,  and  then  it  follows  the  same  conditions  as 
diphtheria  does,  i.  e.,  measles,  scarlatina,  small  pox  and  typhoid 
fever.  What  is  more,  it  complicates  diphtheria  itself  in  certain 
cases. 

Yet,  when  the  disease  is  observed  from  the  beginning,  we 
have  the  advantage  of  several  important  differential  signs.  Al- 
though often  taking  on  a  grayish  or  even  a  brown  tint,  the 
false  membranes  of  diphtheria  are  usually  white  at  first,  and  if 
they  become  brown  later  on,  it  results  from  what  they  absorb 
from  the  blood  which  oozes  from  beneath  them,  or  at  their  cir- 
cumference. The  eschar,  on  the  contrary,  though  often  pre- 
ceded by  a  yellowish  spot,  assumes  from  the  very  first  the  ap- 
pearance of  gray,  brown,  blackish,  or  entirely  black  patches. 
It  is  cast  off  like  the  eschars,  much  more  slowly  than  the  false 
membrane,  and  leaves  behind  it  losses  of  substance,  often  con- 
siderable, while  in  diphtheria  the  mucous  membrane  is  almost 
always  intact. 


2/8  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

The  mucous  membrane,  red,  swollen  and  tense  in  diphtheria, 
is  livid,  purple  and  uidematous  in  gangrene.  The  fetid  odor, 
moreover,  is  different  in  the  two  cases.  In  the  first  it  is  a  pe- 
culiar odor  quite  different  from  that  of  gangrene,  it  appears  at 
an  advanced  stage  of  the  disease,  when  the  false  membranes 
with  their  absorbed  blood  begin  to  putrefy,  while  in  the  sec- 
ond it  is  the  characteristic  odor  of  gangrene  and  is  perceived 
from  the  first. 

Adenitis  is  less  common  in  gangrenous  pharyngitis  than  in 
diphtheria,  but  the  difference  is  not  sufficiently  marked  to  be 
of  value. 

The  general  symptoms  being  almost  exactly  the  same  in 
both,  there  is  nothing  to  be  hoped  for  on  that  side.  Albumin- 
uria constitutes  a  valuable  element  in  the  diagnosis.  Although 
it  may  not  be  found  in  diphtheria,  its  presence  will  suffice  to 
exclude  gangrenous  pharyngitis. 

When  gangrene  complicates  diphtheria,  it  is  usually  at  a  cer- 
tain interval  after  the  beginning  that  the  symptoms  of  sphacelus 
appear.  To  the  false  membranes  there  succeed  eschars  which 
install  themselves  on  the  sites  of  the  former,  either  after  their 
detachment  or  before.  At  the  moment  when  the  false  mem- 
brane becomes  detached,  the  subjacent  mucous  membrane,  in- 
stead of  looking  healthy  and  with  its  normal  aspect,  appears 
covered  with  an  eschar.  The  odor  becomes  gangrenous;  and 
we  have  before  us  the  transformation  of  the  first  process.  This 
is  a  difficult  point  in  diagnosis,  and  is  possible  only  in  frankly 
characterized  cases,  while  in  others  doubt  is  unavoidable. 

Ulcero-tncnibraiwus  Pharyngitis. — This  form  of  pharyngitis, 
which  is  most  often  only  a  propagation  of  the  lesions  of  ulcero- 
membranous stomatitis,  finds  its  place  with  gangrenous  pharyn- 
gitis, for  it  also  belongs  to  the  necrotic  process.  The  mortified 
products,  which  are  its  principle  characteristic,  may  pass  for 
false  membrane.  The  diagnosis  is  singularly  facilitated  by  the 
almost  constant  co-existence  of  an  ulcero-membranous  stoma- 
titis, the  characteristics  of  which  differ  completely  from  those 
of  diphtheritic  stomatitis,  as  I  shall  show  further  on.  When 
the  stomatitis  is  lacking  it  is  necessary  to  be  more  cautious. 


LOCALIZATION    OF     DIPHTHERIA.  ^79 

General  symptoms  are  almost  wanting  in  ulcerative  pharyn- 
gitis. There  is  no  fever,  no  albuminuria  and  adenitis  is  absent 
or  is  very  slight.  The  objective  symptoms  may  be  deceptive, 
especially  at  first.  At  this  time  the  mortified  surface  presents, 
principally  upon  the  uvula  and  upon  the  palate,  a  glossy  ap- 
pearance which  may  cause  it  to  be  confounded  with  a  false 
membrane.  Upon  the  tonsils,  on  the  contrary,  in  place  of  a 
single  eschar,  are  found  many  pieces.  But  the  surface  soon 
ceases  to  be  smooth.  It  becomes  downy  and  grayish,  its  out- 
line, rounded  and  perpendicular,  is  surrounded  by  a  reddened 
and  swollen  mucous  membrane.  Elimination  occurs,  not  by  a 
detachment  of  the  borders,  as  in  diphtheria  but  by  a  sort  of 
abrasion. 

If  some  doubt  should  remain  a  microscopical  examination  of 
the  products  would  demonstrate  their  gangrenous  nature.  They 
have,  in  fact,  as  principal  constituent  elements,  epithelial  cells 
and  elastic  fibers  joined  together  in  bundles.  These  fibers  are 
derived  from  the  chorion  of  the  mucous  membrane  which  is  in 
part  destroyed  by  the  sphacelus. 

Mugnet  (Aphtha). — Confusion  will  rarely  occur  except  in 
cases  where  the  thrush  is  very  confluent,  and  covers  the  ton- 
sils and  palate  with  a  large  and  thick  coating.  But  under 
these  very  circumstances  the  confluence  is  not  the  same  every- 
where. Upon  the  lips  and  upon  the  gums  the  thrush  will  al- 
most always  appear  with  its  true  characteristics,  i.  e.,  under  the 
form  of  small  disseminated  white  points,  like  clots  of  curdled 
milk,  and  separated  by  intervals  of  inflamed  mucous  mem- 
brane. Microscopic  examination  should,  moreover,  show  the 
presence  of  o'idium  albicans  in  this  coating. 

Herpetic  Pharyngitis. — A  confusion,  much  to  be  regretted, 
exists  in  many  minds,  between  herpetic  pharyngitis  and  diph- 
theria. Imbued  with  the  false  idea  that  diphtheria  is  always 
announced  by  large,  thick,  gray  pseudo-membranous  patches 
and  by  a  serious  general  appearance,  imbued  with  that 
error  so  dangerous  in  its  consequences,  they  have  separated 
from  diphtheria  cases  of  discrete  pseudo-membranous  pharyn- 
gitis to  class  them  as  herpetic  pharyngitis.     Far  be  it  from  me 


280  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

to  think  of  denying  herpes  of  the  fauces.  The  description  of 
it  which  Gubler,  with  his  well-known  talent,  has  given,  should 
be  preserved,  for  it  establishes  an  incontestable  fact,  the 
knowledge  of  which  fulfills  certain  desiderata. 

But  the  danger  is  so  much  the  more  formidable,  because  a 
deceptive  security  may  prevent  its  recognition.  An  almost 
irresistible  current  has  driven  a  large  number  of  physicians  to 
always  see  herpetic  pharyngitis,  when  the  trouble  was  benign 
diphtheria.  Clinical  physicians  of  great  merit,  Roger  and 
Peter,  have  fully  recognized  this  abuse  and  have  noted  the  ex- 
istence of  benign  diphtheria.  Such  is  also  the  opinion  of 
Barthez,  and  my  own. 

I  have  sufficiently  insisted  on  the  different  modes  of  begin- 
ning in  diphtheritic  pharyngitis  for  that  clinical  point  to  have 
become  evident.  Benign  diphtheria  appears  in  certain  cases 
with  the  aspect  of  herpetic  pharyngitis.  How  can  these  two 
morbid  conditions,  so  similar  in  appearance,  but  so  different  in 
reality,  be  distinguished? 

If  the  disposal  of  the  false  membranes  in  small,  round  and 
discrete  patches,  be  not  sufficient,  the  presence  of  herpetic 
patches  upon  the  lips,  while  indeed  more  convincing,  has  still 
but  a  restricted  value.  I  have  several  times  seen,  and  other 
observers  have  as  well,  the  severest  diphtheritic  pharyngitis 
and  the  most  infectious  croup  coinciding  with  Jierpes  labialis. 

The  only  time  when  herpetic  pharyngitis  can  be  recognized 
is  at  the  first,  while  the  vesicles  are  still  intact,  or  at  least  while 
intact  vesicles  are  still  found  beside  the  minute  ulcerations. 
When,  on  the  contrary,  they  have  all  vanished  and  have  been 
replaced  by  small  round  ulcerations,  covered  with  a  white, 
thin  and  adherent  exudate,  there  is  only  a  probability  in  favor 
of  herpes.  When  the  vesicles  are  coherent,  and  their  union 
has  formed  a  somewhat  large  concretion,  the  difficulty  is  still 
greater.  The  existence  around  the  circumference  of  these 
patches  of  circular  indentations  which  prove  the  union  of 
small  round  patches,  has  indeed  been  claimed  as  a  distinctive 
sign.  But  on  the  other  hand,  these  indentations  are  quickly 
effaced,  and  the  contour  becomes  uniform,  while  on   the  other 


LOCALIZATION    OF    DIPHTHERIA.  28 1 

the  diphtheritic  false  membrane  may.be  formed  by  the  fact  of 
the  confluence  of  small  patches.  The  ulceration  of  herpes  and 
the  false  membrane  of  diphtheria  have  then  such  numerous 
points  of  resemblance  that  it  becomes  more  difficult  than  ever 
to  discriminate  one  from  the  other. 

If,  then,  the  presence  of  an  herpes  labialis,  the  disposal  of 
the  products  in  rounded  and  discrete  spots,  their  white  aspect 
and  their  thinness  may  not  exclude  them  from  diphtheria,  it  is 
evident  that  the  objective  characteristics  are  not  sufficient  for 
a  diagnosis  except  in  those  rare  cases  in  which  the  vesicles 
can  be  found  again. 

The  absence  of  submaxillary  adenitis  and  of  albuminuria 
present  a  certain  value,  but  these  symptoms  may  be  wanting 
even  in  fully  confirmed  cases  of  diphtheria. 

Only  a  probability  can,  therefore,  be  conceded  in  favor  of 
herpes  of  the  pharynx,  and  doubt  persists  in  the  greater  num- 
ber of  cases.     The  course  of  the  disease  cannot  be  foreseen. 

Under  these  circumstances,  the  coui'se  to  be  followed  should 
be  the  same  as  though  diphtheria  were  unquestionable.  The 
usual  precautions  should  be  taken  and  the  patient  isolated.  If 
it  be  proved  subsequently  that  the  suspected  pharyngitis  was 
only  a  herpes,  one  will  have  come  off  with  a  few  useless  meas- 
ures, but  if  the  opposite  error  has  been  committed,  if,  by  mis- 
taking a  diphtheritic  pharyngitis  for  herpes,  the  physician  has 
neglected  isolation  of  the  patient,  he  exposes  himself  to  re- 
grets for  his  exaggerated  faith  in  herpetic  pharyngitis ;  for  be- 
nign diphtheria,  though  pseudo-herpetic  in  the  patient,  not 
content  with  transmitting  itself  to  other  members  of  the  family, 
may  determine  in  the  latter  one  of  its  gravest  forms,  and  cause 
terrible  ravages. 

Examples  of  malignant  diphtheria  transmitted  by  subjects 
affected  with  benign  diphtheria  are  common,  and  numerous 
cases  of  it  have  been  cited.  The  most  striking  one  is  that  of 
Gilletti,'  of  sad  memory.  Peter,  who  records  this  instance,  in 
which  he  was  one  of  the  actors,  reports  that  a  household  ser- 
vant in  a  certain  family  was  attacked  with  an  angina,  pro- 
nounced  by  the   physician  to   be    common  membranous  sore 


2C>2  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

throat.  No  precautions  were  taken,  but  the  patient  was  al- 
lowed in  the  midst  of  the  family.  Moreover,  she  rapidly  re- 
covered. But  after  a  few  days  the  baby  of  the  house  was  at- 
tacked with  diphtheritic  pharyngitis,  soon  followed  by  croup 
which  resulted  in  death  in  spite  of  tracheotomy  performed  by 
Peter.  Gillette,  who  was  also  called  in  consultation,  and  who 
remained  a  long  time  with  the  patient,  contracted  the  disease 
and  died  of  a  generalized  diphtheria.  Two  deaths  were  the  re- 
sult of  that  error  in  diagnosis. 

Diphtheria  Without  Diphtheria.      (Diphtherie  sans  Diph- 

therie), 

I  have  spoken  before  of  those  cases  of  pharyngitis  without 
false  membrane,  which  are,  in  times  of  epidemic  observed  in 
centers  where  numerous  manifestations  of  diphtheria  are  en- 
countered. In  families  it  is  not  rare  to  see  these  sore  throats 
alternating  with  pseudo-membranous  sore  throats.  They  be- 
have like  simple  sore  throat.  They  only  have  a  greater  ten- 
dency to  produce  sub-maxillary  swelling. 

The  diagnosis  can  never,  in  such  cases,  be  positively  made, 
as  the  most  striking  objective  expression  of  diphtheria,  viz.,  the 
false  membrane,  is  wanting.  Analogy  is  the  principal  argu- 
ment. There  can  be  no  objection  to  admitting  that  the  false 
membrane  may  be  lacking  in  diphtheria,  like  the  eruption  in 
measles  or  in  scarlatina,  especially  when  one  of  these  cases  of 
pharyngitis  without  false  membrane  is  seen  to  be  acquired  from 
a  case  of  pseudo-membranous  pharyngitis,  and  to  transmit,  in 
its  turn,  another  exudative  pharyngitis.  In  this  case,  an  un- 
questionable anatomical  diagnosis  should  not  be  pretended. 
It  is  rather  a  matter  of  rational  diagnosis  imposed  by  the  laws 
of  general  pathology,  and  by  the  study  of  the  habits  of  the  dis- 
ease. 

Laryngeal  Diphti^eria. 

The  symptoms  of  croup  consist  in  alterations   of  the  cough, 
of  the  voice,  and  of  the   respiration.     Whenever  these   symp- 
toms are  met  with  in  patients  already  suffering  from  diphtheri 
tic  pharyngitis,  no   doubt  is  possible  ;  their  cause  is  evidently 
the  propagation  of  the  pharyngeal  lesions  into  the  larynx.    But 


LOCALIZATION  OF  DIPHTHERIA.  283 

at  the  time  when  the  patient  comes  under  observation,  the 
pharyngitis  may  be  wanting,  either  because  it  is  already  past, 
or  because  it  has  been  altogether  absent.  Under  these  circum- 
stances, which  are  not  rare  as  I  have  shown  before,  the  task 
becomes  more  difficult.  The  only  irrefutable  symptom  ot 
croup,  is  the  expectoration  of  false  membranes  representing 
fragments  of  a  cylinder,  and  appearing  to  be  detached  from  the 
air-passages.  This  is  the  substantial  diagnosis,  it  is  the  lesion 
itself.  Since  this  very  important  sign  is  often  wanting,  croup 
may  be  confounded  with  different  affections  of  the  air-passages, 
which  also  occasion  difficulties,  of  cough,  of  voice,  and  of  res- 
piration. These  affections  are :  Laryngitis  stridulosa,  severe 
ac7Ue  laryngitis,  cedema  glottidis,  foreign  bodies^  polypi  of  the 
larynx  and  capillary  bronchitis. 

Laryngitis  Stridulosa  or  Spasmodic  Laryngitis. — There  is  no 
disease  with  which  the  physician  should  make  himself  more  ia- 
miliar.  It  is  the  terror  of  parents  who  confound  it  with  croup, 
and  I  might  say,  the  nightmare  of  the  physician  whose  sleep  it 
disturbs  more  than  all  other  diseases  put  together.  Nineteen 
times  out  of  twenty,  a  physician  who  has  anything  to  do  with 
diseases  of  children,  is  suddenly  awakened  by  some  one  crying 
and  demanding  his  immediate  assistance  :  "Hurry,  doctor,"  he 
exclaims,  "my  baby  has  the  croup." 

The  commencement  of  the  case  should  result  in  reassuring 
the  physician  almost  completely,  and  in  making  him  suspect 
false  croup.  He  may,  while  on  the  way,  encourage  his  guide 
a  little.  Examination  of  the  patient  confirms  the  anticipated 
diagnosis,  and  justifies  the  prognosis,  in  the  immense  majority 
of  cases.  In  fact,  one  of  the  best  characteristics  of  laryngitis 
stridulosa,  the  best  one  as  I  believe,  and  certainly  the  most 
striking,  is  its  sudden  onset  during  the  night.  The  child  has 
gone  to  bed  perfectly  well,  or  more  accurately,  with  a  slight 
cold.  Between  lo  o'clock  in  the  evening  and  2  o'clock  in  the 
morning  it  wakes  up,  a  prey  to  a  hoarse  paroxysmal  cough 
which  is  at  the  same  time  loud  and  accompanied  by  oppressed 
breathing  with  retraction  (of  the  lower  end  of  the  sturnum)  and 
soon,  by  the  attack  of  suffocation.     Often  the  cough   and  the 


284  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

dyspnoea  do  not  interrupt  its  sleep,  which  persists  up  to  the 
point  where  the  paroxysm  of  suffocation  approaches.  That 
feature  announced  by  so  great  a  fuss,  makes  more  noise  on,  the 
whole,  than  it  does  harm,  as  we  shall  soon  see,  for  it  does  not 
announce  croup  but  laryngitis  stridulosa. 

With  the  suddenness  of  the  onset  of  false  croup  should  be 
contrasted  the  mode  of  invasion  of  true  croup,  which  is  almost 
always  preceded  by  a  pharyngitis  or  by  a  pseudo-membranous 
coryza,  and  which,  even  in  those  cases  where  it  comes  on  sud- 
denly, almost  always  begins  with  alterations  of  the  cough  and 
of  the  voice,  the  attack  of  suffocation  coming  on  later. 

Some  other  differential  symptoms  will  serve  to  elucidate  the 
diagnosis.  The  cough  is  entirely  different  in  the  two  cases. 
In  croup  it  is  infrequent,  harsh  at  first,  and  finally  muffled.  In 
laryngitis  stridulosa  it  is  frequent  and  at  the  same  time  hoarse 
and  loud,  imitating  more  or  less  the  crowing  of  a  cock  or  the 
barking  of  a  puppy.  This  cough  is  the  true  croupy  cough 
which  points,  as  we  see,  not  to  croup,  but  to  false  croup.  It 
indicates  that  the  vocal  cords  still  vibrate,  although  in  un- 
wonted sounds.  That  of  croup  is,  on  the  contrary,  stuffed  up 
by  the  false  membranes  which,  according  to  Trousseau's  com- 
parison, act  like  a  bit  of  wet  parchment  upon  the  reed  of  a 
clarionette.  The  course  of  the  disease  differs  essentially  in 
the  two  cases.  Sudden  as  suffocation  is  in  false  croup,  it  is 
just  as  short  in  duration.  Often  the  attack  is  single,  the  dysp- 
noea decreases,  the  retraction  diminishes,  the  cough  becomes 
moist,  and  order  is  restored.  The  patient  falls  asleep  again, 
and  w'akes  up  after  a  long  refreshing  sleep,  retaining  only  a 
slightly  hoarse  cough  from  its  nocturnal  attack.  When  the 
attacks  are  repeated  they  gradually  diminish.  If  the  op- 
pression persist  during  the  interval  the  laryngo-tracheal  whist- 
ling disappears.  The  retraction  alone  remains,  and  that  gradu- 
ally diminishes.  How  different  is  the  course  of  croup.  In 
place  of  an  explosion,  followed  by  a  lull,  we  find  ourselves  in 
the  presence  of  a  series  of  symptoms,  the  intensity  of  which 
is  constantly  increasing,  from  the  simple  hoarse  cough  with 
neither  paroxysms  nor  suffocation,  indicative  of  simple  laryn- 


LOCALIZATION  OF  DIPHTHERIA.  285 

gitis,  to  the  dyspnoea,  which,  by  a  gradual  progression  reaches 
asphyxia,  by  passing  through  attacks  of  suffocation  and  con- 
tinued dyspnoea. 

There  is  often  no  fever  at  all  in  false  croup,  at  least  when 
the  latter  does  not  begin  in  the  course  of  a  slight  bronchitis, 
and,  in  any  case,  it  diminishes  rapidly  after  the  first  attack. 
The  existence  of  a  submaxillary  swelling,  or  the  presence  of 
albumen  in  the  urine,  would  be  evidence  in  favor  of  croup. 
The  gravest  difficulties  may  arise.  The  intensity  of  the  suffo- 
cation may  be  such  as  to  compromise  the  life  of  the  patient. 
This  supposition  is  rarely  realized,  for  laryngitis  stridulosa  is 
always  benign.  One  case  only,  the  one  which  Trousseau  re- 
ported, is  known  to  have  ended  fatally.  The  course  of  the 
symptoms  and  the  character  of  the  cough  in  very  severe  cases 
will  almost  always  indicate  the  true  nature  of  the  disease.  We 
should,  nevertheless,  keep  watch  of  the  patient,  with  a  fear  of 
actual  suffocation,  and  hold  ourselves  in  readiness  for  trache- 
otomy. In  croup  without  pharyngitis,  with  an  abrupt  begin- 
ning and  a  fulminant  course,  the  diagnosis  has  for  its  data  the 
growing  intensity  of  the  symptoms  and  the  ejection  of  false 
membranes.  In  case  of  doubt  we  should  act  as  though  it 
were  a  question  of  croup,  and  shape  our  course  accordingly. 

Trousseau  speaks  of  the  possibility  of  laryngitis  stridulosa 
in  patients  suffering  with  common  or  herpetic  pharyngitis. 
Here  the  embarrassment  is  augmented  by  the  uncertainty  as 
to  the  nature  of  the  pharyngitis.  What  I  have  said  of  the 
rarity  of  herpes  of  the  fauces,  and  of  the  errors  too  frequently 
committed  by  confounding  it  with  certain  forms  of  diphtheria, 
is  such  as  to  prompt  a  very  justifiable  reserve  as  to  the  nature 
of  a  laryngitis  which  might  develop  under  like  circumstances. 
Yet,  if  it  were  fully  shown  that  the  pharyngitis  was  frankly 
herpetic,  there  would  be  good  reasons  in  favor  of  simple  laryn- 
gitis. However,  it  should  not  be  forgotten  that  diphtheritic 
croup  has  been  seen  coincident  with  herpes  of  the  lips  and 
with  that  of  the  fauces.  In  spite  of  all  these  precautions,  and 
a  careful  examination  of  the  symptoms,  the  diagnosis  may  re- 
main undecided.     The  only  probability   in   favor  of  croup  is 


286  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

the  increasing  severity  of  the  dyspnoea.  Moreover,  the  doubt 
would  not  last  long,  for  laryngitis  stridulosa  is  decided  within 
twenty-four  hours,  or  two  days  at  most. 

Severe  Acute  Laryngitis. — Rarely  primary,  this  form  of  lar- 
yngitis is  very  often  secondary  being  met  especially  during 
the  course  of  measles,  scarlatina,  or  small-pox,  and  in  a  num- 
ber of  febrile  affections  like  pneumonia,  bronchitis,  etc.  A 
certainty  of  the  primary  origin  of  the  laryngitis  in  question 
would,  therefore,  be  very  important  in  eliminating  the  idea  of 
diphtheria ;  in  fact,  measles,  scarlatina  and  small-pox  are 
found  among  the  commonest  causes  of  croup.  The  distinction 
is  established  by  means  of  the  following  signs : 

When  laryngitis  is  primary  it  begins  with  a  violent  febrile 
condition,  and  when  it  is  secondary  the  fever  reappears  if  it 
had  subsided.  In  croup,on  the  contrary,  the  fever  is  rarely  high. 
The  cough  is  hoarse  from  the  beginning,  but  is  not  muffled; 
it  is  frequent,  in  place  of  being  infrequent,  as  in  croup,  and  it 
is  violent  and  tearing  (rasping).  Dyspnoea  is  intense  from  the 
beginning,  it  increases  rapidly,  and  is  continuous,  almost  never 
assuming  an  intermittent  form.  Retraction  is  uncommon. 
Pressure  upon  the  larynx  causes  a  sharp  pain.  Still  oftener 
than  laryngitis  stridulosa,  simple  laryngitis  may  cause  such 
suffocation  that  tracheotomy  becomes  necessary.  Millard  cites 
one  such  case,  and  I  have  met  with  several.  A  pseudo-mem- 
branous expectoration  during  or  after  the  operation  would  be, 
in  the  absence  of  any  other  diphtheritic  manifestation,  the  sole 
proof  of  croup.  Although  cases  of  simple  laryngitis,  submit- 
ted to  tracheotomy,  have  often  been  taken  for  croup,  the  error 
was  not  prejudicial  to  the  patient  so  long  as  the  laryngeal 
symptoms  reached  asphyxia.  The  fever  continues  throughout 
the  disease,  and  general  symptoms,  such  as  delirium  and  con- 
vulsions, sometimes  accompany  it. 

GLdema  of  the  Glottis. — The  repetition  of  the  attacks  of  suf- 
focation, the  dyspnoea  and  retraction  (tirage)  which  persist  in 
the  interval,  the  character  of  the  cough  and  of  the  voice, 
which  are  dull  and  muffled,  and  the  difficulty  in  deglutition, 
give   laryngeal   dropsy   a   great   resemblance    to    croup.     The 


LOCALIZATION    OF    dRiTHERIA.  -^7 

course  of  the  disease  usually  differs.  As  oedema  is  ordinarily 
secondary  to  chronic  affection  of  the  larynx,  its  course  is  slow, 
and,  in  place  of  reaching  its  limit  in  a  few  days,  or  even  m  a 
few  hours,  like  croup,  it  often  requires  several  weeks. 

When  the  oedema  succeeds  a  sub-acute  inflammation  of  the 
larynx,  it  comes  on  very  rapidly,  a  few  hours  being  sufficient, 
and  the  diagnosis  becomes  very  difficult.  A  little  boy,  twenty- 
three  months  old,  who  had  been  coughing  for  four  days,  en- 
tered Saint  Eugenia,  No.  13,  Saint  Benjamin's  ward,  having  had 
attacks  of  suffocation.  An  emetic  and  the  action  of  the  va- 
porarium brought  some  relief,  but  during  the  night  a  more  vio- 
lent attack  carried  him  off;  before  aid  could  be  obtained  for 
him.  The  autopsy  revealed  the  existence  of  an  oedema  of  the 
glottis.  This  very  suddenne^ss,  joined  with  the  absence  of 
pharyngitis  should  exclude  diphtheritic  laryngitis.  Yet  ful- 
minant croup  sometimes  progresses  in  the  same  manner. 
Moreover,  the  disease  ending  in  suffocation  in  both  cases,  the 
treatment  is  the  same,  and  the  diagnosis  is  of  little  value  from 
this  standpoint.  It  is  not  so  as  to  prognosis.  When  the  as- 
phyxia is  removed  by  tracheotomy,  acute  oedema  rapidly  re- 
covers, but  too  rarely  does  croup  do  so.  The  submaxillary 
swelling,  indicated  by  many  authors  as  an  important  differen- 
tial sign,  should  lose  much  of  the  value  accorded  to  it.  Aden- 
itis, in  fact,  when  it  is  considerable,  whatever  be  its  nature,  is 
itself  a  cause  of  oedema  of  the  larynx,  by  reason  of  the  pres- 
sure which  it  exercises  upon  the  vessels  of  the  neck.  After 
scarlatina,  notably,  such  cases  are  not  rare.  I  have  published 
a  very  interesting  one.  In  another,  a  girl  of  twelve  years, 
oedema  of  the  glottis  was  determined  by  a  glandular  enlarge- 
ment of  strumous  origin,  occupying  the  submaxillary  glands  on 
both  sides  and  in  such  a  way  that  the  two  tumors  joined  by 
passing  in  front  of  the  neck.  Tracheotomy  was  performed  and 
a  cure  obtained.  Thus  the  testimony  of  adenitis  does  not 
favor  croup,  more  than  it  does  oedematous  laryngitis. 

The  circumstances  under  which  the  disease  is  produced, 
should  be  carefully  taken  under  consideration.  The  existence 
of  a  cervical  tumor,  or  of  a   disease  which  readily  brings  on 


Sc 


288  DIPHTHERIA,    CTIOUP    AND    TRACHEOTOMY. 

laryngeal  lesions,  as  do  measles,  small-pox,  whooping  cough, 
typhoid  fever,  and  tuberculosis,  should  favor  diagnosis  of  oedema 
of  the  glottis.  The  appearance  of  laryngeal  symptoms  in  a 
subject  already  suffering  from  anasarca,  would  make  one  sus- 
pect also  laryngeal  dropsy.  Yet  in  these  very  conditions  error 
is  still  possible.  I  saw  at  Saint  Eugenie  a  patient  three  years 
old  who  entered  the  hospital  with  anasarca,  with  attacks  of 
suffocation  and  with  albuminuria.  There  was  no  history,  and 
he  had  no  submaxillary  swelling  but  what  was  attributable  to 
the  facial  oedema.  The  diagnosis  was,  oedema  of  the  glottis 
resulting  from  acute  Bright' s  disease  with  anasarca.  Tracheo- 
tomy was  formally  indicated  and  was  performed,  but  at  the 
moment  of  opening  the  trachea,  an  effort  at  coughing  forced 
from  the  wound  a  large  piece  of  false  membrane.  During  the 
following  days  other  false  membranes  were  expelled.  Thus  we 
had  to  deal  with  croup.  Did  the  anasarca  depend  upon  a  pri- 
mary nephritis  or  did  it  depend  upon  the  diphtheria,  which  is 
possible,  but  rare  ?  This  was  difficult  to  determine  in  the  ab- 
sence of  a  history.  In  spite  of  that  complex  condition,  the  pa- 
tient recovered.  And  now,  to  conclude,  I  give  a  case  in  which 
diagnosis  was  impossible  during  life,  and  was  furnished  only  by 
the  autopsy.  It  relates  to  an  oedema  of  the  glottis  in  a  patient 
suffering  from  diphtheritic  pharyngitis  and  coryza.  A  girl  of 
six  years  entered  Saint  Eugenie  on  account  of  a  diphtheritic 
pharyngitis  which  was  perfectly  well  marked  and  accompanied 
by  coryza,  considerable  adenitis  and  swelling,  and  by  albumin- 
uria. Two  days  after  her  entrance  she  showed  laryngeal  com- 
plications. An  extension  of  the  false  membrane  into  the  larynx, 
was  naturally  supposed.  The  general  condition  was  so  bad 
and  blood  poisoning  so  profound  thattracheotomy  was  decided 
to  be  useless.  Death  occurred  caused  rather  by  the  infection 
than  by  asphyxia.  To  our  general  surprise,  no  false  membrane 
at  all  was  found  in  the  air-passages.  The  tonsils  alone  pre- 
sented some  remnants  of  it.  The  borders  of  the  epiglottis  and 
the  aryteno-epiglottidean  ligaments  were  converted  into  thick 
mammelated,  tremulous  pads  forming  tubercles  as  large  as 
peas,  and  permitting  a  turbid  serous  liquid  to  ooze  out  on  press- 
ure after  incision. 


LOCALIZATION    OF    DIPHTHERIA.  2^9 

Direct  exploration  of  the  epiglottis  by  means  of  the  finger, 
and  Jaryngoscopic  examination  have  been  vaunted  as  the  final 
means  of  decision.  ■  These  means  have  great  value  in  theory  ; 
but  their  application  is  necessarily  subordinate  to  the  tolerance 
of  the  fauces.  Usually  very  difficult  with  children,  they  are 
impracticable  with  patients  whose  breathing  is  oppressed  and 
who  experience  reflex  movements  followed  by  suffocation,  at 
the  least  irritation  of  the  fauces. 

Spasm  of  the  Glottis. — The  sudden  onset  of  the  attacks  of 
suffocation,  the  perfect  freedom  of  the  respiration  between 
times,  and  their  frequent  coincidence  with  contraction  of  the  ex- 
tremities or  with  convulsions  will  leave  no  doubt  at  all  as  to 
diagnosis.  We  may  add  that  spasm  is  met  with  especially  in 
early  infancy. 

Foreign  Bodies  in  the  Larynx. — Paroxysms  of  cough,  and  at- 
tacks of  suffocation  are  the  results  of  that  accident,  but  beyond 
the  fact  that  the  history  usually  puts  one  on  the  right  track, 
the  cough  and  the  voice  are  not  at  all  of  the  same  sound  as  in 
croup.  Auscultation  of  the  larynx,  by  revealing  a  flapping  or 
valve-like  noise,  indicates  the  presence  of  a  foreign  body  in 
that  cavity.  Besides  there  is  often  heard  at  a  distance  an  in- 
terrupted scraping,  a  to  and  fro  sound. 

The  foreign  body  may  come  from  the  interior,  in  which  case 
it  consists  usually  of  entozoa,  of  lumbricoids  in  particular, which 
pass  out  of  the  digestive  passages  and  find  their  way  into  the 
larynx.  Noted  by  Haller,  these  facts  were  more  fully  brought 
to  light  by  Arronsohn,  Tonnele,  and  by  Barthez  and  RiUiet. 

The  attention  is  not  attracted  at  first,  to  an  accident  of  this 
nature,  yet  some  suspicions  might  be  aroused  if  the  attack  of 
suffocation  came  on  suddenly,  and  in  the  day  time,  in  a  subject 
perfectly  well;  if  also  we  could  learn  that  the  child  was  subject 
to  passing  worms,  and  if  we  could  be  sure  that  no  foreign  body 
had  come  from  the  outside.  Introduction  of  the  finger  into  the 
back  part  of  the  fauces  sometimes  enables  the  body  of  the  lum- 
bricoid  to  be  felt. 

Retro-pharyngeal  Abscess. — Its  acute  character,  the  difficulty 
of  deglutition  and  the  extreme  dyspnoea,  may  cause  retropha- 


290  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

ryngeal  abscess  to  be  confounded  with  croup.  In  the  former 
case  the  dyspnoea  is  usually  continuous,  while  the  dysphagia  is 
not  in  proportion  to  the  condition  of  the  fauces,  upon  which 
false  membranes  are  not  found,  and  constriction  of  the  jaws  is 
often  very  pronounced.  The  neck  is  rigid  and  motionless. 
The  muscles  of  the  neck  may  be  contracted.  Pressure 
upon  the  cervical  vertebrae  is  often  very  painful.  The  neck 
is  swollen,  tumefied  and  oedematous.  This  tumefaction  is 
very  different  from  that  which  characterizes  diphtheria,  a 
tumefaction  due  at  once  to  the  adenitis  and  to  a  soft  swelling 
of  the  cellular  tissue.  With  abscess  there  is  a  general  puffiness 
descending  lower  than  in  croup,  and  finally,  in  the  former  there 
is  found  to  exist  upon  the  posterior  wall  of  the  pharynx,  a  red, 
smooth,  tense,  and  fluctuating  tumor  caused  by  the  pushing 
forward  of  the  pharyngeal  mucous  membrane. 

Capillary  Bronchitis. — The  excessive  dyspnoea  and  the  cy- 
anosis, which  are  met  with  in  suffocative  catarrh,  when  it  at- 
tains its  maximum  intensity,  may  palm  it  off  for  croup.  I 
have  seen  certain  cases  in  which  suffocation  was  so  predomi- 
nant that  the  error  was  followed  out  clear  to  the  end,  and 
tracheotomy  was  performed.  Yet,  by  not  allowing  the  dysp- 
noea to  have  too  great  weight,  it  will  be  seen  at  once  that  in 
suffocative  catarrh  neither  adenitis,  pharyngitis,  attacks  of  suf- 
focation nor  laryngo-tracheal  whisthng  are  observed.  The 
cough  and  the  voice  preserve  their  usual  tone,  and  auscultation 
shows  the  presence  of  numerous  sibilant  and  subcrepitant 
rales,  almost  always  generalized.  Fever  is  intense.  Respi- 
ration is  considerably  accelerated,  and  from  80  to  100  inspira- 
tions a  minute  may  be  counted. 

Now  that  we  have  learned  to  distinguish  croup  from  other 
diseases,  there  remains  still  one  question  to  be  solved :  Are 
there  several  kinds  of  croup?  In  other  words,  is  such  a  thing 
known  as  non-diphtheritic  croup?  Just  as  benign  diphtheritic 
pharyngitis  has  often  been  denied,  and  turned  into  a  separate 
species,  which  has  been  confounded  with  herpes  of  the  fauces, 
so  the  attempt  has  been  made  to  class  croup  without  apparent 
blood  poisoning  as  a  non-diphtheritic  disease.     Does  not  this 


LOCALIZATION    OF    DIPHTHERIA.  2gi 

distinction,  which  is  evidently  applicable  only  to  cases  which 
are  primary  croup,  arise  from  a  confusion  between  croup  and 
severe  laryngitis  stridulosa  ?  We  have  above  seen  that  there 
are  some  instances  where  the  latter  affection,  though  usually 
benign,  may  be  serious  enough  to  result  in  death.  Here  is  a 
cause  of  error  from  which  we  should  protect  ourselves,  and 
which  may  have  led  astray  the  partisans  of  this  theory.  On 
the  other  hand,  it  is  said  that  the  laryngeal  mucous  membrane, 
when  highly  inflamed,  may  become  covered  with  a  fibrinous 
exudate  which  is  non-diphtheritic.  This  is  a  view  entirely 
theoretical.  If,  in  fact,  we  may,  by  means  of  chemical  irri- 
tants, cause  pellicles  resembling  false  membrane  to  arise  on 
the  laryngeal  mucous  membrane,  there  is  no  proof  that  nature 
spontaneously  produces  like  lesions  in  the  absence  of  diphthe- 
ria. In  making  an  extensive  abstract  of  the  German  termin- 
ology which  makes  two  different  diseases  of  croup  and  diph- 
theria, I  do  not  believe  that  many  observers  have  met,  at 
least  in  our  country,  these  cases  of  non-diphtheritic,  pseudo- 
membranous laryngitis.  West  has  also  given  the  support  of 
his  authority  to  this  theory.  The  following  passage  will  en- 
able us  to  judge  of  it: 

"There  are,  indeed,  two  diseases  which  have  often  been  included  under  the  com- 
mon name  of  croup,  though  the  points  of  difference  between  them  are  at  least  as 
numerous  and  as  important  as  are  those  in  which  they  resemble  each  other.  Oi  these 
two  diseases,  the  one  is  almost  always  idiopathic,  the  other  is  often  secondary ;  the 
one  attacks  persons  in  perfect  health,  is  sthenic  in  its  character,  acute  in  its  conise, 
and  usually  proves  amenable  to  antiphlogistic  treatment;  the  other  attacks  by  pref- 
erence those  who  are  out  of  health  or  who  are  surrounded  by  unfavorable  hygienic 
conditions,  and  is  remarkable  for  the  asthenic  character  of  the  symptoms  which  at- 
tend It.  The  one  selects  its  victims  almost  exclusively  from  among  children,  is  in- 
capable of  being  diffused  by  contagion,  is  governed  in  its  prevalence  by  the  inlluence 
of  season,  temperature  and  climate,  but  rarely  becomes,  in  the  usual  acceptation  ot 
the  term,  an  epidemic ;  while  the  other  attacks  adults  as  well  as  children,  is  propa- 
gated by  contagion,  and  though  it  occasionally  occurs  in  sporadic  form,  is  suscepti- 
ble of  wide-spread  epidemic  prevalence.  The  one  is  developed  out  of  catarrh,  and 
the  amount  of  disease  of  the  respiratory  organs  is  the  exact  measure  of  the  danger 
which  attends  it;  while  the  other  afiects  the  organs  of  respiration,  secondarily,  its 
peril  is  often  altogether  out  of  proportion  to  the  degree  in  which  they  are  involvec, 
and  death  itself  may  take  place  although  they  are  altogether  unaffected.  In  this  latter 
ailment,  too,  a  long  train  of  sequelae  not  unfrequently  remains  after  the   local  symp- 


292  DlPirrilKRlA,    CROUP    AND    TKACiiEOi  OMY, 

tonis  have  been  dissipated ;  the  evidence  of  its  affinity  to  the  class  of  blood  diseases 
rather  than  to  that  of  simple  inflammations.  Cynanche  trachealis, cynanche  laiyngea, 
are  the  appellations  of  the  former;  Home  and  Cheyne,  and  Albers  its  historians. 
Angina  maligna,  the  garotille,  morbus  strangulatorius,  diphtherite  or  diphtheria,  the 
synonyms  of  the  latter ,  Severinus,  Bard,  Starr,  Rumsey,  Bretonneau,  Trousseau  and 
Jenner  some  of  the  writers  who  have  most  carefully  described  it." 

[I  will  here  add  a  further  paragraph  from  West  which  seems 
to  be  quite  pertinent  to  the  present  discussion : 

"Different,  however,  as  the  two  diseases  are,  there  are  yet  between  them  points  of 
similarity  no  less  striking — Fades  non  una,  nee  diversa  tamen — and  the  diagnostic 
difficulties  which  are  thus  almost  inevitable,  are  slill  further  enhanced  by  the  not  in- 
frequent simultaneous  prevalence  of  both  affections."  C.  West,  M.D.,  "Lectures  on 
the  Diseases  of  Infancy  and  Childhood."  Fourth  Am.  Ed.  from  the  5th  revised  and 
enlarged  English  ed.     186S.  p.  310. 

The  following  are  the  conclusions  of  the  Committee  of  the 
Royal  Medico- Chirurgical  Society  appointed  to  report  on  the 
subject  of  membranous  croup  and  diphtheria,  on  which  com- 
mittee Dr.  West  was  at  first  appointed  chairman : 

1.  Membranous  inflammation  confined  to  or  chiefly  affecting  tlie  larynx  and 
trachea  may  arise  from  a  variety  of  causes,  as  follows: 

a.  From  diphtheritic  contagion. 
h.    By  means  of  foul  water  or  of  foul  air  or  other  agents,  such  as  are  commonly  con- 
cerned in  the  generation  or  transmission  of  zymotic  disease  (though  whether  as 
mere  carriers  of  contagions  cannot  be  determined). 

c.  As  an  accompaniment  of  measles,  scarlatina,  or  typhoid,    being    associated  with 

these  diseases  independently  of  any  ascertainable  exposure  to  the  special   diph- 
theritic infection. 

d.  It  is  stated  on  apparently  conclusive  evidence,  although  the  committee  have  not 
had  an  opportunity  in  any  instance  of  exatnining  the  membrane  in  question,  the 
membranous  inflammation  of  the  larynx  and  trachea  may  be  produced  by  various 
accidental  causes  of  irritation,  the  inhalation  of  hot  water  or  steam,  the  contact 
of  acids,  the  presence  of  a  foreign  body  in  the  lar\'nx,  and  a  cut  throat. 

2.  There  is  evidence  in  cases  which  have  fallen  under  the  observation  of  members 
of  the  committee,  and  are  mentioned  in  the  tables  appended,  that  membranous  affec- 
tion of  the  larynx  and  trachea  has  shortly  followed  exposure  to  cold,  but  the  know- 
ledge of  the  individual  cases  is  not  sufficient  to  exclude  the  possible  intervention  or 
co-existence  of  other  causes.  The  majority  of  the  cases  of  croupal  symptoms  defi- 
nitely traceable  to  cold  appear  to  be  of  the  nature  of  laryngeal  catarrh. 

3.  Membranous  inflammation,  chiefly  of  the  lai7nx  and  trachea,  to  which  the  term 
"membranous  croup"  would  commonly  be  applied,  may  be  imparted  by  an  influence, 
epidemic  or  of  other  sort,  which  in  other  persons  lias  produced  laryngeal  diphtheria. 

4.  And  conversely,  a  person  suffering  with  the  membranous  affection  of  the  air-pass- 


LOCALIZATION   OF    DIPHTHERIA.  293 

ages  such  as  would  commonly  be  termed  membranous  croup,  may  communicate  lo 
another  a  membranous  condition  limited  to  the  pharynx  and  tonsils,  which  will  com- 
monly be  regarded  as  diphtheritic. 

It  is  thus  seen  that  the  membranous  affection  of  the  larynx  may  arise  in  connection 
with  common  inflammation  or  widi  specific  disorders  of  several  kinds,  the  most  com- 
mon of  which  in  this  relation  is  that  which  produces  similar  change  elsewhere,  and 
is  recognized  as  diphtheria.  In  the  larger  numberof  cases  of  membranous  affection  of 
the  larynx  the  cause  is  obscure  (i.  e.,  in  any  given  case  it  is  difficult  to  predicate  the 
particular  cause  in  that  case). 

Among  those  in  which  it  is  apparent,  common  irritation  seldom  presents  itself  as 
thtr  source  of  the  disease,  accidental  injury  is  but  very  infrequently  productive  of  iL 
But  few  cases  of  undoubted  origin  from  exposure  to  cold  are  on  record.  On  the 
other  hand,  in  a  very  large  number  of  cases  infective  or  zymotic  influence  is  to  be 
traced. 

The  membrane,  even  when  chiefly  laryngeal,  is  more  often  than  not  associated 
with  some  extent  of  a  similar  change  in  the  pharynx  or  tonsils;  and  whether  we 
have  regard  to  the  construction  of  the  membrane,  or  to  the  constitutional  state,  as 
evinced  by  the  presence  of  albumen  in  the  urine,  it  is  not  practicable  to  show  an  ab- 
solute line  of  demarcation  (save  what  depends  upon  the  position  of  the  membrane) 
between  the  pharyngeal  and  laryngeal  forms  of  the  disease. 

The  facts  before  the  committee  only  warrant  them  in  the  view  that  when  it  ob- 
viously occurs  from  a  zymotic  cause  or  distinct  infection  and  primarily  affects  the 
pharynx,  constitutional  depression  is  more  marked,  and  albuminuria  more  often  and 
more  largely  present,  though  in  both  conditions  some  albumen  in  the  urine  is  more 
frequently  present  than  absent.  The  most  marked  division  indicated  by  the  facts 
before  the  committee  is  that  between  membranous  and  non-membranous  laryngitis. 
The  committee  suggest  that  the  term  croup  be  henceforth  used  wholly  as  a  clinical 
definition  implying  laryngeal  obstruction  occurring  with  febrile  symptoms  in  children. 
Thus  croup  may  be  membranous  or  not  membranous,  due  to  diphtheria  or  not  so. 
The  term  diphtheria  is  the  anatomical  definition  of  a  zymotic  disease  which  may 
•r  may  not  be  attended  with  croup. 

The  committee  propose  that  the  name  membranous  lar^'ngitis  should  be  employed 
iD  order  to  the  avoidance  of  confusion  whenever  the  knowledge  of  the  case  is  such 
as  to  allow  of  its  application.  Chairman,  W.  HowsHiP  Dickinson. 

C.  Hilton  Fagge. 

Samuel  Gee. 

J.  F.  Payne. 

H.  G.  HowsE. 

R.  H.  Semple. 

H.  S.  Greenfield,  Sec'y.] 

It  is  quite  difficult  to  apprehend,  from  this  passage,  the  ex- 
act thought  of  the  EngHsh  physician  (West).  Does  he  mean 
to  speak  of  two  forms  of  pseudo-membranous  laryngitis  of 
different  nature?  In  the  second  of  the  two  diseases  he  evi- 
dently has  in   view    infectious   croup.     To  what   pathological 


294  DIPHTHERIA,    CROUP    AND    TRACHEOIOMY. 

type  can  the  first  be  adapted?  It  is  applicable  at  least  to  two 
morbid  states,  which  the  author  seems  to  confound,  viz.,  laryn- 
gitis stridulosa  and  primary  croup  without  marked  blood 
poisoning.  In  fact,  the  larger  share  of  the  characteristics  which 
he  gives  to  the  first  disease  can  be  assigned  to  laryngitis 
stridulosa.  The  latter  is  developed,  as  is  well  known,  under 
the  form  of  catarrh,  attacks  children  only,  because  of  the  re- 
stricted dimensions  of  their  larynx,  is  neither  epidemic  nor 
contagious,  and  prevails  almost  exclusively  during  cold 
weather. 

If  it  refer  to  simple  croup,  without  very  evident  blood 
poisoning,  which  is  sometimes,  as  I  have  also  shown,  accom- 
panied by  a  certain  inflammatory  condition,  it  is  easy  to  prove 
that  the  differences  between  the  two  diseases  are  much  less 
evident  still.  Who  has  not  seen  a  frankly  infectious  croup, 
beginning  in  subjects  in  perfect  health  and  living  in  the  best 
hygienic  conditions.?  Who  has  not  observed,  in  times  of  epi- 
demic, the  most  locaHzed  croup,  and  the  least  infectious  in 
appearance,  having  been  transmitted  to  a  healthy  individual, 
by  another  suffering  from  malignant  diphtheria,  and  vice  versa? 
If  the  first  sometimes  assumes  the  inflammatory  type,  the  sec- 
ond may  also  do  likewise  at  the  beginning.  Croup,  the  most 
simple  to  outward  appearance,  may  be  accompanied  by  al- 
buminuria and  followed  by  paralysis.  We  add  further,  that  in 
the  sthenic  form,  of  which  the  author  speaks,  the  tendency  to- 
ward generalization  of  the  false  membranes  is  much  greater 
than  in  the  infectious  form,  the  opposite  of  what  we  observe 
in  France.  The  confusion  evidently  comes  from  croup,  local- 
ized in  the  larynx  and  appearing  exempt  from  blood  poison- 
ing. But  as  I  shall  show  more  in  detail  when  I  treat  of  the 
nature  of  diphtheria,  this  absence  of  blood  poisoning  is  only 
apparent.  Often  these  cases  of  croup  which  appear  so  simple 
are  observed  in  surroundings  where  diphtheria  exists;  often 
they  originate  from  cases  evidently  diphtheritic,  and  they  often 
transmit  severe  forms  of  diphtheria.  It  is  also  not  rare  to  see 
those  which  have  the  most  benign  aspect  at  the  beginning 
afterwards  assume  characteristics   of  the   most   marked  blood 


LOCALIZATION    OF    DIPHTHERIA.  295 

poisoning.  One  of  the  arguments  upon  which  the  partisans  of 
simple  croup  depend  is  the  absence  of  pharyngitis.  I  have  in- 
dicated how  much  that  reason  is  worth.  Much  oftener  than 
one  would  suppose,  the  pharyngitis  is  very  slight,  is  unper- 
ceived,  or  has  already  disappeared  when  the  patient,  suffering 
from  croup,  presents  himself  for  observation.  I  record,  for 
the  first  time,  a  very  important  case  of  croup,  in  which  pha- 
ryngitis appeared  to  be  wanting,  when  the  autopsy  demon- 
strated that  the  false  membranes  had  developed  behind  the 
tonsils  and  from  thence  had  extended  into  the  larynx.  Ad- 
mitting the  absence  of  pharyngitis,  these  localized  non-in- 
fectious, simple  croups,  common  sore  throats,  as  certain  au- 
thors would  have  them,  should  recover  with  the  greatest  ease, 
when  tracheotomy  has  brought  relief  to  the  asphyxia.  The 
results  should  be  analogous  to  those  of  oedema  of  the  glottis, 
but  much  shorter  since  it  is  a  question  of  an  acute  disease. 
Unfortunately  recovery  is  far  from  being  the  rule,  even  in 
those  cases  which  are  so  simple  in  appearance.  What  is  it, 
then,  that  prevents  recovery,  if  it  be  not  the  very  infection 
which  was  latent  from  the  first?  The  conclusion  which  to  me 
appears  most  justified  is  that  croup,  like  every  manifestation 
of  diphtheria,  appears  under  many  forms,  with  or  without  ap- 
parent blood  poisoning,  with  a  sthenic  or  an  asthenic  charac- 
ter, but  that  it  is  difficult,  if  not  impossible,  to  prove  the  ex- 
istence of  a  non-diphtheritic  pseudo-membranous  laryngitis. 

Diphtheritic  Coryza. — This  local  determination  of  diphtheria 
cannot  be  confounded  with  any  other  disease.  Although  the 
existence  of  a  pseudo-membranous  coryza,  aside  from  diph- 
theria, has  been  admitted,  that  notion  is  no  better  justified  in 
this  case  than  in  that  of  croup.  The  important  point  is  not  to 
deny  diphtheritic  coryza.  In  a  patient  free  from  any  other 
diphtheritic  manifestation,  the  coryza,  insignificant  in  itself, 
may  enable  the  invasion  of  croup  to  be  foreseen.  When  su- 
pervening in  a  subject  suffering  from  diphtheritic  pharyngitis 
it  notably  aggravates  the  prognosis.  It  should,  therefore,  al- 
ways be  looked  for.  A  serous,  sero-purulent,  or  especially  a 
sero-sanguinolent  discharge,  or  an  epistaxis,  should   make  us 


296  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

suspect  it.  Often  the  oozing  is  insignificant,  and  pressure  must 
be  exercised  upon  one  nostril  or  the  other,  to  make  it  escape. 
To  confirm  the  corpus  delecti  (the  essential  cause)  we  must  not 
wait  till  the  false  membrane  appears  externally,  or  till  pseudo- 
membranous fragments  are  thrown  out,  which  may  fail.  It  is 
necessary  to  examine  the  interior  of  the  nasal  fossae  by  par- 
tially opening  the  nostrils  or  by  introducing  a  nasal  speculum, 
which  will  enable  one  to  recognize  the  condition  of  the  ante- 
rior portion  of  that  cavity.  If  this  exploration  gives  no  re- 
sult, the  posterior  orifice  should  be  examined,  which  can  be 
done  by  means  of  the  rhinoscope. 

PseiLdo-Membranous  Bronchitis. — An  increase  of  the  fever 
and  oppressed  breathing,  and  the  frequency  of  respiration 
rising  to  80  or  100  inspirations  per  minute,  are  the  symptoms 
common  to  bronchial  diphtheria,  and  to  all  its  thoracic  compli- 
cations. 

The  establishment  of  the  symptoms  indicated  will  enable 
one  to  make  a  diagnosis,  viz.,  dry,  crackling  sounds  and  ab- 
sence of  vesicular  murmur  over  a  certain  extent  of  the  chest. 
These  signs  have  only  a  relative  value,  for  they  may  be  masked 
by  those  of  other  pulmonary  lesions.  A  diagnosis  cannot  be 
expected,  except  from  a  single  sign,  viz.,  from  the  expectora- 
tion of  tubular  and  branched  pseudo-membranous  fragments. 
This  is  the  pathognomonic  and  indubitable  characteristic. 

Oculo-Palpebral  Diphtheria. 

Purulent  ophthalmia  with  fibrinous  deposits  is  the  only- 
lesion  with  which  ocular  diphtheria  could  be  confounded. 
Some  important  characteristics  differentiate  these  two  morbid 
states.  In  the  former  case  the  discharge  is  abundant,  puru- 
lent, and  lasts  during  the  whole  of  the  disease,  while  in  the 
second  it  is  turbid  and  grayish,  disappearing  almost  corn 
pletely  during  the  exudative  period,  to  reappear  at  the  mo- 
ment of  elimination.  In  the  first  the  conjunctiva  is  red  and 
granular,  and  the  eyelids  are  tense  and  oedematous ;  in  the 
second  the  mucous  membrane  is  smooth  and  yellowish,  and  th 
eyelids  are  hard,  and  form  a  sort  of  resisting  cap.     The  exu- 


LOCALIZATION  OF    DIPHTHERIA.  29/ 

dates  of  the  former  are  wholly  different  from  the  smooth  and 
thin  false  membrane  of  the  latter.  The  diagnosis  presents 
certain  difficulties  only  at  the  period  of  elimination,  but  the  co- 
existence of  other  diphtheritic  manifestations  will  render  the 
diagnosis  clear. 

Special  authors  have  discussed  the  existence  of  pseudo- 
membranous conjunctivitis,  developed  apart  from  any  specific 
action.  The  question  has  not  been  as  yet  definitely  solved,  but 
its  solution  can  be  foreseen  by  recalling  what  has  been  said  of 
other  manifestations  of  diphtheria. 

Diphtheritic    Otitis. 

Always  accompanied  by  the  symptomatic  array  of  pharyn- 
gitis, coryza,  and  often  of  croup,  diphtheritic  otitis  media  often 
is  overlooked  in  very  young  patients,  at  least  during  its  first 
period.  The  otorrhoea  alone  permits  the  diagnosis  to  be  made. 
Yet,  in  older  subjects,  the  recrudescence  of  the  fever,  the  lan- 
cinating character  of  the  pain,  and  its  locality,  which,  very  dif- 
ferent from  that  of  pharyngitis,  is  felt  in  the  temple,  and  about 
the  temporo-maxillary  articulation,  and  tinnitus  aurium,  ver- 
tigo, vomiting,  and  deafness  will  direct  the  line  of  research. 
Buccal    Diphtheria. 

This  local  manifestation  should  be  distinguished  from  aphthae, 
from  gangrene  of  the  mouth  and  from  ulcero-membranous 
stomatitis. 

1st  AphtlicE. — Isolated  aphthae  will  never  be  confounded  with 
buccal  diphtheria.  The  complete  absence  of  general  symp- 
toms, the  presence,  at  the  beginning,  of  a  vesicle  followed  later 
by  an  ulceration  with  perpendicular  borders,  sharply  defined, 
quite  deep,  or  appearing  so  from  the  swelling  of  the  surround- 
ing tissues,  of  rounded  form,  small  size,  forbid  any  confusion 
between  these  two  morbid  states,  although  the  aphthae  may 
also  be  covered  with  a  fibrinous  exudate.  Only  this  exudate 
is  thin  and  has  no  tendency  to  grow  thicker  nor  to  become  pu- 
trid. 

When  the  aphthae  are  numerous  and  confluent,  the  diagnosis 
is  more  difficult,  and  it  is  certain  that  several  authors  have  de- 
scribed, under  this    name,  lesions   which  were   nothing  other 


298  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

than  those  of  buccal  diphtheria.  Yet  there  is  a  notable  differ- 
ence between  these  two  conditions.  While  the  confluent 
aphthae  very  often  give  rise  to  a  febrile  attack  which  may  last 
from  one  to  two  days,  there  is  no  resemblance  at  all  between 
this  general  condition,  and  that  which  pertains  to  diphtheria. 
The  glandular  swelling,  while  possible,  is  rare,  and  of  slight  in- 
tensity. The  ulceration  possesses,  in  gross, the  characteristics  of 
isolated  aphthae.  In  place  of  the  white,  thick,  and  salient,  false 
membrane  of  diphtheria,  a  true  ulceration  is  seen,  the  general 
form  of  which  is  round,  and  whose  edges  are  sharply  perpen- 
dicular. 

2nd.  Gangrene  of  the  Month. — The  morbid  product  is  not  a 
false  membrane,  but  a  real  eschar  with  a  well  pronounced  gan- 
grenous odor.  The  surrounding  mucous  membrane  is  grayish. 
The  cheek  is  swollen,  oedematous,  tense,  shining,  marbled,  and 
of  a  purple  red.  At  the  centre  of  this  engorgement,  one  point 
is  found  to  be  particularly  indurated.  Salivation  is  abundant. 
It  is  mingled  with  an  infectious,  sanguinolent,  and  finally  sani- 
ous  and  putrescent  liquid.  Considerable  destruction  of  tissue, 
of  which  the  most  remarkable  is  the  complete  perforation  of 
the  cheek,  is  often  the  end  of  this  sphacelus. 

Buccal  gangrene  is  ordinarily  isolated,  and  is  not  compli- 
cated by  any  lesion  of  the  fauces,  larynx,  or  respiratory  pas- 
sages. 

A  grave  adynamic  condition  frequently  accompanies  this  lo- 
cal lesion. 

j^.  Ulcero-membranons  Stomatitis. — By  reason  of  its  site, 
which  is  so  often  the  alveolar  border  of  the  gums,  this  disease 
has  been  confounded  with  buccal  diphtheria.  The  analogy  is, 
in  fact,  quite  great,  and  it  may  be  conceived  that  before  the 
description  given  by  Bergeron,  ulcero-membranous  stomatitis 
was  taken  for  diphtheria.  This  is  what  appears  from  the  works 
of  Bretonneau  and  of  Trousseau.  Actually,  the  differences 
which  separate  these  two  conditions  are  perfectly  well  known. 

The  history  of  ulcero-membranous  stomatitis  shows  yet  again 
to  what  grave  errors  one  exposes  himself  by  taking  the  lesion 
as  the  sole  basis  of  the  classification  of  diseases.     This   stoma- 


LOCALIZATION  OF    DIPHTHERIA.  299 

titis  is  the  type  of  the  anatomical  process  which  the  Germans 
designate  by  the  name  of  diphtheria.  The  inflammatory  exu- 
dation forms  not  only  upon  the  surface,  but  also  in  the  sub- 
stance of  the  mucous  membrane,  which  it  infiltrates  to  a  varia- 
ble depth,  and  which  it  destroys  to  the  same  extent.  It  is, 
consequently,  eliminated,  leaving  a  loss  of  substance.  Thus,  if 
we  admit  that  which  moreover  is  inexact,  viz.,  the  identity  of 
the  lesion  in  this  stomatitis  and  diphtheria,  we  are  led  to  con- 
found two  affections,  which,  aside  from  a  superficial  resem- 
blance, are  as  dissimilar  as  possible  in  all  their  symptoms.  In 
fact,  ulcerative  stomatitis,  a  disease  of  wretchedness  and  want, 
which  develops  in  organisms  deteriorated  by  bad  hygiene  or 
in  convalescents,  this  ulcerative  stomatitis,  the  reverse  of  buc- 
cal diphtheria.aimost  always  occupies  the  alveolar  border  of  the 
gums,  often  has  for  its  point  of  origin  a  carious  tooth,  extends 
in  length  and  breadth  along  the  gum,  lays  bare  the  teeth, 
reaches  the  lips  and  the  inner  surface  of  the  cheeks,  more  rare- 
ly the  palate  or  the  tonsils,  and  produces  oval  shaped  ulcera- 
tions. These  ulcerations  have  an  unhealthy  appearance,  being 
covered  with  a  grayish  detritus ;  their  borders  are  irregular, 
often  detached. 

The  tendency  to  spread  is  slightly  marked.  Only  one  side 
of  the  mouth  is  attacked  in  the  larger  number  of  cases.  The 
odor  is  fetid,  much  more  so  than  in  diphtheria.  The  cheeks 
and  the  lips  are  often  somewhat  swollen.  In  case  of  great  in- 
tensity there  is  now  and  then  a  little  submaxillary  adenitis,  but 
this  engorgement  is  never  comparable  to  that  of  diphtheria. 
While  it  may  reach  the  tonsils,  and  the  velum  palati,  ulcero- 
membranous pharyngitis  does  not  extend  to  the  larynx,  nor 
does  it  ever  present  analogous  lesions  in  other  parts  of  the  body. 
While  it  often  attacks  subjects  whose  health  is  already  af- 
fected, ulcerative  stomatitis  rarely  aggravates  their  condition, 
for  it  is  almost  never  accompanied  by  general  symptoms.  Left 
to  itself  it  runs  its  course  very  slowly,  but  under  the  influence 
of  appropriate  medication  it  becomes  rapidly  modified. 

These  characteristics  differ  sufficiently  from  those  which  buc- 
cal diphtheria  presents,  to  render  confusion  impossible. 


f 


300  diphtheria,  croup  and  tracheotomy. 

Diphtheria  of  the  Anus  and  of  the  Genitals. 

Herpes  with  ulceration,  and  gangrene  are  the  only  affections 
which  could  be  taken  for  diphtheria  on  these  organs. 

ist.  Herpes. — The  verge  of  the  anus,  the  labia  majora  and 
minora,  the  glans  penis,  and  the  prepuce,  are  quite  often  the 
seat  of  herpes,  which  we  must  avoid  confounding  with  diph- 
theria. If  the  vesicles  are  discrete,  there  can  be  no  doubt,  for 
they  leave  behind  them  a  small,  rounded,  superficial  ulceration 
with  a  yellowish  floor,  and  the  surrounding  mucous  membrane 
is  slightly  inflamed.  When  the  vesicles  are  numerous  and  con- 
fluent, the  diagnosis  is  more  difficult.  Instead  of  separate  ul- 
cerations, there  appears  an  ulceration  sometimes  quite  exten- 
sive, the  diagnosis  of  which  requires  an  attentive  examination. 
The  greatest  difficulties  are  met  with  in  the  female,  on  account 
of  the  arrangement  which  the  numerous  folds  of  mucous  mem- 
brane about  the  labia  majora  and  minora,  give  to  the  ulcer. 
These  ulcerations  have  often  an  unhealthy  look,  giving  rise  to 
quite  an  abundant  discharge,  while  their  floor  is  covered  with 
a  yellowish  detritus.  After  carefully  washing  the  surface,  we 
should  see  if  we  cannot  find  ulcerations  in  the  neighborhood, 
either  upon  the  mucous  membrane,  or  the  skin,  which  have 
come  from  isolated  vesicles.  Their  discovery  would  be  of  very 
great  importance,  and  would  settle  the  diagnosis.  On  the 
other  hand,  in  examining  the  ulcer  we  find  that  its  floor  is  cov- 
ered with  a  yellowish  exudate  which  is  adherent,  that  its  edges 
are  sharply  perpendicular  and  while  in  general  they  assume  a 
rounded  form,  their  circumference  is  made  irregular  by  circu- 
lar dentations  separated  by  reentering  angles, and  which  repre- 
sent a  part  of  the  contour  of  the  little  vesicles  around  the  edge, 
the  other  part  being  fused  with  the  vesicles  placed  nearer  the 
centre. 

In  the  female,  care  should  be  taken  to  separate  the  labia 
minora,  as  the  ulceration  sometimes  extends  along  their  internal 
surface  and  even  into  the  vagina. 

To  these  local  characteristics  must  be  added  the  absence 
of  general  symptoms,  and  of  any  other  diphtheritic  manifesta- 
tions. 


LOCALIZATION    OF    DIPHTHERIA.  3OI 

2nd.  Gangrene. — Gangrene  of  the  vulva  should  principally  be 
kept  in  mind,  as  this  is  much  the  more  common.  That  of  the 
verge  of  the  anus,  while  infinitely  more  rare,  presents  the  most 
evident  objective  features.  That  of  the  vluva  is,  because  of  its 
situation,  more  difficult  to  examine.  It  is  oftenest  observed 
after  eruptive  fevers  and  typhoid  fever  or  among  women  during 
confinement.  Dr.  Chavanne  reported  the  history  of  an  epi- 
demic of  vulvo-vaginal  diphtheria  occurring  among  women  dur- 
ing confinement,  which  epidemic  was  in  reality  only  an  epi- 
demic of  gangrene.  In  many  cases  the  gangrene  appears  un- 
der the  form  of  a  true  eschar,  and  the  diagnosis  is  evident,  but 
sometimes,  especially  among  women  during  confinement,  the 
distinction  is  more  difficult. 

The  objective  symptoms  are  not  always  sufficient,  as  diph- 
theria itself  may  be  complicated  with  gangrene.  Yet,  the 
diphtheritic  patch  may  in  most  cases  be  distinguished  from  the 
eschar,  which  oftenest  assumes  a  gray  or  brown  tint,  exhales  a 
distinctly  gangrenous  odor,  and  produces  the  most  extensive 
destruction  of  tissue.  Gangrene  is  limited  to  the  vulva,  while 
vulvar  diphtheria  coincides  with  other  diphtheritic  manifesta- 
tions ;  and  then,  even  when  it  begins  at  the  vulva  it  may  be 
followed  by  pharyngitis,  as  numerous  examples  prove.  Al- 
buminuria and  a  secondary  paralysis  will  decide  in  favor  of 
diphtheria. 

This  diagnosis,  as  we  see,  is  determined  more  by  the  aid  of 
the  rational  symptoms,  than  by  that  of  the  objective  features. 

Diphtheria  of  the  Skin. 
Hospital  gangrene  might  be,  in  some  cases,  confounded  with 
diphtheria  of  the  skin,  for  this  error  has  been  to  a  certain  de- 
gree sanctioned  by  the  improper  name  oi  dipJitheritis  ofivounds 
given  by  Robert  to  hospital  gangrene,  and  by  the  classification 
of  Boussuge,who  classes  this  affection  among  the  diphtheroids. 
Billroth  affirms  the  identity  of  hospital  gangrene  and  diphtheria. 
All  the  French  school,  as  well  as  several  German  authors, 
among  whom  I  will  cite  Raser  and  Eiscnschitz,  protest  against 
this  assimilation.  In  fact,  if  the  surfaces  attacked  with  hospital 
gangrene  are  at  first  covered  with  a  grayish  layer,  the  altera- 


302  DIPHTHERIA,  CROUP    AND    TRACHEOTOMY, 

tion  instead  of  extending  superficially  as  in  diphtheria,  gains  in 
depth,  converts  the  tissues  into  a  putrescent  mass  which  dis- 
charges an  infectious  ichor,  often  infiltrated  with  blood,  and 
extends  down  to  the  bones  which  it  denudes,  strips  them  of 
their  periosteum,  and  leaves  them  a  prey  to  necrosis.  It  develops 
after  amputations  among  those  who  are  enfeebled  by  privation 
and  who  live  in  want.  None  of  the  signs  of  diphtheria  are  met 
with,  neither  reproductions  in  other  organs,  albuminuria,  nor 
paralysis. 

Ulceration  of  the  skin,  especially  that  which  is  caused  by 
vesicants,  possesses  at  times  a  strong  resemblance  to  diphtheria 
of  the  skin.  In  the  former  case,  the  floor  of  the  ulcer  is  gray, 
and  sanious;  while  the  fibrinous  exudation  is  absent  or  much 
less  marked,  than  in  diphtheria.  Nevertheless,  the  diagnosis 
is  sometimes  very  obscure  when  there  is  not  found  at  the  same 
time,  some  other  manifestation  of  diphtheria.  The  presence  or 
absence  of  an  epidemic  of  diphtheria,  will  be  of  importance  in 
the  decision. 

Diphtheritic    Paralysis. 

The  subject  of  diphtheritic  paralysis,  has  entered  profoundly 
enough  into  medical  science,  so  that  paralyitic  symptoms  de- 
veloped on  the  part  of  the  velum  palati,  of  the  pharynx,  and 
the  larynx,  do  not  compel  us  to  seek  immediately  for  the  exis- 
tence of  a  pharyngitis  among  their  antecedents.  It  is  not  pro- 
bable that  the  error  is  still  committed,  of  attributing  the  rough- 
ness of  the  voice,  and  the  difficulty  of  deglutition,  to  syphilitic 
lesions  or  to  hysteria.  When  the  paralysis  is  generalized,  er- 
ror is  more  easy,  especially  if  the  pharyngitis  be  lost  sight  of. 
In  these  cases,  meanwhile,  and  in  those  where  a  history  is  lack- 
ing, we  may  even  find  ourselves -in  the  midst  of  diseases  which 
afford  a  resemblance  to  diphtheritic  paralysis. 

The  absolute  integrity  of  the  intellectual  faculties  will  forbid 
a  belief  in  the  existence  of  a  progressive  general  paralysis,  in 
subjects  whose  movements  are  uncertain,  and  whose  speech  is 
embarrassed. 

The  melancholy,  indolence,  fixity  of  expression,  apparent 
hebetude,    amblyopia,    strabismus,     emaciation     and    slowing 


LOCALIZATION    OF    DIPHTHERIA.  3O3 

of  the  pulse,  will  not  be  taken  for  symptoms  of  a  tubercular 
meningitis  at  its  beginning,  or  of  cerebral  tubercles.  With  these 
symptoms,  in  fact,  will  be  found  in  cases  of  diphtheria,  paraly- 
sis of  the  limbs  or  of  the  pharynx,  which  are  not  the  result  of 
the  onset  of  these  maladies,  and  which  usually  present  an  inter- 
mittent character.  The  ataxia  which  has  been  noted  several 
times  in  the  movements,  will  not  be  taken  either  as  attributable 
to  locomotor  ataxia,  when  the  different  paralyses  which  follow 
diphtheria,  are  discovered.  The  order  followed  by  the  paraly- 
sis, in  its  successive  invasion  of  organs,  is  one  of  the  best  ele- 
ments of  the  diagnosis.  While  that  order  is  not  constant,  it  is 
common  enough  to  be  taken  into  serious  consideration.  Al- 
most always,  paralysis  of  the  fauces  forms  the  first  phenomenon. 
It  exists  only  for  a  certain  time,  and  it  is  often  at  the  time 
when  movement  returns  to  this  part,  that  it  diminishes  or  dis- 
appears in  other  parts  of  the  body.  When  it  affects  the  limbs, 
the  lower  ones  are  attacked  first,  and  the  upper  extremities  af- 
terward, and  then  the  eyes  and  the  respiratory  organs.  The 
hemiplegic  form  presents  also  certain  difficulties,  but  we  know 
that  the  hemiplegia  is  only  apparent,  and  that  the  side  which 
appears  healthy  is  really  also  enfeebled. 

An  important  point  to  be  remarked,  is,  that  the  paralysis  fol- 
lows a  protracted  course,  and  becomes  generalized  only  gradu- 
ally and  after  quite  a  long  time.  It  never  occurs  all  at  once. 
These  considerations  have  only  a  secondary  value  in  all  those 
cases  in  which  faucal  paralysis  exists,  which  alone  is  enough 
to  affirm  the  nature  of  the  disease,  or  to  call  attention  to  its 
antecedents,  while  they  are  of  especial  value  in  those  in  which 
the  history  of  the  disease  presents  neither  angina  nor  faucal 
paralysis. 

It  may  happen,  finally,  when  certain  of  these  facts  remain 
doubtful,  that  the  diagnosis  may  be  confirmed  in  an  unforeseen 
manner,  by  the  faucal  paralysis,  which,  in  place  of  opening  the 
scene,  sometimes  terminates  it. 

Etiology — For  a  long  time  diphtheria  appeared  in  the  form  of 
epidemics.  We  find  in  science  the  account  of  a  great  number 
of  epidemics,  some  general  and  extensive,  invading  a  city  or 


304  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

an  entire  section  of  country,  others  circumscribed  to  a  single 
ward,  to  a  hospital,  an  educational  institution,  and  sometimes 
even  to  an  apartment  (Vigla).  Such  are  those  which  formed 
the  basis  of  the  celebrated  works  of  Bretonneau,  Trousseau  and 
others.  At  first  exceptional  and  limited  to  certain  countries, 
they  have  become  more  frequent,  and  have  extended  to  regions 
where  they  had  remained  unknown.  Very  few  of  the  countries 
of  Europe  have  escaped  them.  In  certain  large  cities,  notably 
in  Paris,  diphtheria  has  become  endemic.  Since  1856  it  has 
prevailed  in  this  capital  continually,  with  frequent  periods  of 
intensification  as  appears  from  discussions  which  have  taken 
place  at  the  sessions  of  the  learned  societies,  and  from  reports 
of  the  "  commission  for  prevailing  diseases."  In  England  and 
in  Germany  it  has  followed  the  same  progression.  It  is,  there- 
fore, difficult  to  follow  in  many  places,  the  course  of  the  dis- 
ease and  to  study  the  conditions  of  its  development.  In  fact, 
this  information  can  be  furnished  only  by  the  epidemics.  By 
these  we  are  enabled  to  investigate  the  climatic  influences 
which  preside  over  the  development  of  diphtheria,  and  to  seek 
its  mode  of  transmission.  While  there  are  countries  in  which 
epidemics  are  more  difficult  to  examine,  there  are  others  in 
which  it  has  been  possible  to  observe  them  recently  with  care. 
A  comparison  of  the  latter  with  those  which  served  as  a  basis 
of  the  works  of  ancient  authors,  might  possibly  clear  up  this 
part  of  the  history  of  diphtheria.  The  accounts  published  be- 
fore 1862  are  too  well  known  to  require  me  to  repeat  the  de- 
scription; I  shall  always  be  able  to  consult  them  in  elucidating 
certain  points.  The  following  brief  remarks  refer  to  epidemics 
recently  studied.  In  England  Dr.  Radcliffe,  secretary  of  the 
Epidemiological  Society  of  London  gives  in  the  following 
terms  the  history  of  diphtheria  in  that  country  :  "At  the  be- 
ginning of  the  present  century  there  had  been  only  a  few 
sporadic  isolated  cases  of  diphtheria.  The  first  real  epidemic 
dates  in  1849;  it  prevailed  from  1849  to  1850  in  Pembroke- 
shire. The  second  arose  in  Cornwall  in  1855.  There  were  al- 
ways a  few  sporadic  cases.  During  a  portion  of  1856  the 
epidemics  became  more  numerous,  and  more  frequent.  In 
1859  diphtheria  became  in  England  a  veritable  endemic." 


LOCALIZATION    OF    DIPHTHERIA.  3O5 

In  America,  Dr.  Wynne  announced,  in  his  report  on  the  epi- 
demics of  1855  to  1861,  a  notable  extension  of  the  disease  in 
the  Western  Hemisphere.  He  mentioned  epidemics  at  Lima 
in  1855,  and  in  1858  ;  in  California  in  1855 ;  at  Albany  in  1858, 
and  in  New  York  City  in  1859.  The  mortality  averaged  about 
10  per  cent.  The  epidemics  extended  by  interruptions  and  ag- 
gravations without  continuity. 

[An  epidemic  of  diphtheria  occurred  in  and  about  Leesville 
Ohio,  in  1860-61.  Dr.  J.  H.  Stephenson  sends  me  a  very  in- 
teresting report  of  it,  and  his  experience  with  it.  It  was  the 
first  of  the  disease  ever  known  in  the  county,  and  the  first  he 
had  ever  seen.  The  first  case,  that  of  a  young  lady,  occurred 
in  July.  On  the  sixth  day  (third  of  attendance)  "she  coughed 
up  a  very  heavy  membrane  of  a  dark  color  and  a  perfect 
cast  of  the  trachea."  The  membrane  reformed,  and  she  died 
on  the  tenth  day  of  the  disease.  No  other  case  occurred  till 
winter.  Then  the  disease  spread — whole  families  were  pros- 
trated. The  epidemic  extended  over  a  territory  of  about  eight 
miles  square.  In  a  neighborhood  five  miles  distant  it  v/as  very 
fatal.  In  one  family  four  died.  In  one  family  under  his  care, 
two  brothers  died  in  thirty-six  hours.  In  some  cases  the  mouth 
became  gangrenous,  and  the  teeth  fell  out  before  death.  In  a 
few  cases  there  was  a  scarlatinal  eruption.  Some  cases  as- 
sumed the  hsemorrhagic  form — these  all  died.  In  one  case  ot 
pregnancy  there  was  miscarriage  of  a  dead  foetus — dead,  evi- 
dently, for  some  days.  A  light  deposit  was  no  guarantee 
against  extension  to  the  larynx;  it  occurred  as  frequently  in 
these  as  in  cases  with  thick,  dense  deposits.  There  were 
many  other  cases  of  sore  throat  not  classed  with  the  genuine 
disease.     In  his  practice  there  were  seven  deaths. 

This  description  (given  here  very  briefly)  accords  very 
closely  with  hundreds  of  local  epidemics  before  and  since  in 
various  parts  of  the  country.  Its  cause  and  manner  or  agency 
of  introduction,  and  in  many  cases  its  spread,  were  en- 
tirely  unknown. 

Dr.  A.  G.  Browing  of  Mt.  Carmel,  Ky.,  reports  :  Diphtheria 
had  prevailed   in  that  region   since    1858,    disappearing   in  the 


306  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

summer  months.  In  the  winter  of  1865-6  Dr.  B.  and  his 
brother  treated  thirty-seven  cases  with  the  loss  of  one. 

Dr.  Bedford  Brown,  of  Alexandria,  Va.,  reports  to  the  Vir- 
ginia State  Medical  Society,  1883,  his  experience  since  1856. 
"The  first  case  that  had  ever  appeared  in  that  section,"  a 
boy  10  years  old,  soon  died.  It  soon  spread  all  over  the 
country.  "  Old  Watson  "  makes  no  allusion  to  it  whatever. 
"Wood,"  in  1852,  devotes  about  two  pages  to  a  very  imperfect 
description  of  the  local  features.  Entire  families  were  pros- 
trated with  the  disease,  and  many  died.  "  Previous  to  the  first 
case  of  genuine  diphtheria  (malignant  ?)  which  I  saw  in  the 
spring  of  1856,  for  a  period  extending  over  about  nine  years, 
cases  of  true  membranous  laryngitis,  or  what  is  known  as  mem- 
branous croup  came  under  my  observation  and  professional 
care  during  every  winter  and  spring.  The  appearance  of  this 
affection  sporadically  was  expected  to  make  annual  visitations. 
They  pursued  the  usual  course  of  that  disease,  some  ending  in 
recovery  after  expulsion  of  the  false  membrane,  but  the  great 
majority  proving  fatal  solely  and  alone  from  mechanical  ob- 
struction of  the  respiration  by  the  membranous  exudation. 
This  was  alone  the  cause  of  death."  (Any  cases  of  trache- 
otomy ?)  The  doctor  seems  to  have  failed  to  see  the  simi- 
larity in  nature  between  the  sporadic  and  the  epidemic  forms 
of  this  membranous  disease — diphtheria. 

Local  epidemics  in  Illinois,  reported  by  Dr.  B.  F.  Crummer, 
of  Warren,  Jo  Daviess  County,  Illinois  State  Medical  Society. 
Transactions,  1880  :  i.  A  mother  came  to  Warren  from  Iowa 
City,  where  diphtheria  prevailed  in  fatal  form,  bringing  her 
boy  of  seven  years,  hoping  thereby  to  escape  the  disease.  Af- 
ter five  days  the  boy  had  diphtheria,  pharyngeal  in  localization, 
and  later  faucal  paralysis,  as  the  doctor  witnessed,  but  recov- 
ered within  two  weeks.  This  woman  was  visiting  friends,  who 
had  children,  she  having  received  positive  assurance  from  her 
physician  that  it  was  quite  safe  to  do  so,  no  means  of  disinfec- 
tion, however,  having  been  used.  In  three  unfortunate  families 
(relatives)  the  disease  developed,  and  proved  fatal  in  eight 
cases;    a    number    of    the   older    children     recovered,    having 


LOCALIZATION    OF    DIPHTHERIA.  30/ 

had  "diphtheritic  sore  throat."  Ten  other  caseb  with  four 
deaths  in  other  families,  could  be  traced  directly  to  the  same 
original  eight  cases. 

2.  A  minister  removed  to  the  vicinity  of  Warren  from  a 
Wisconsin  village  where  scarlet  fever  and  diphtheria  were  epi- 
demic. His  large  family  soon  all  had  fever  and  •'  cankered 
sore  throat,"  but  all  recovered.  The  people  were  advised  by  a 
certain  pseudo-doctor  of  a  new  school  that  diphtheria  should  not 
be  classed  with  contagious  diseases.  Visiting  was  unrestrained, 
and  the  disease  spread  to  every  family  having  young  children. 
A  lady  whose  children  were  just  recovering,  one  of  them  hav- 
ing paralysis,  kindly(!)  volunteered  to  nurse  an  invalid  friend, 
two  miles  distant.  Result:  death  of  two  interesting  children 
from  diphtheria  in  the  invalid's  family.  Total  number  of  cases 
of  this  epidemic,  twenty-six,  with  seven !  deaths. 

3.  In  Rush  Township,  mostly  confined  to  one  school  dis- 
trict, diphtheria  was  imported  in  January  from  Stephenson 
County,  where  the  disease  was  rife,  by  two  boys,  aged  respect- 
ively 14  and  16.  They  had  been  on  a  visit  during  the  holidays. 
On  their  return  they  both  had  headache,  sore  throat,  but  were 
not  confined  to  bed.  Domestic  remedies  only  were  used,  and 
they  went  to  school  most  of  the  time ;  their  schoolmates,  how- 
ever, complained  of  their  stinking  breath.  Soon  a  six-year- 
old  child  of  the  same  family  was  taken  seriously  ill,  and  a  few 
hours  before  death  a  diagnosis  was  made,  by  a  physician,  of 
diphtheria.  The  disease  spread  rapidly,  and  in  the  course  of 
six  or  seven  weeks  numbered  filty-eight  cases,  with  seventeen 
deaths,  about  30  per  cent.  One  family  lost  five  young  child- 
ren, and  another  four,  several  older  ones  in  each  instance  re- 
covering. In  this  one  county  thirty-one  precious  lives  were 
lost  from  a  preventable  disease.  Twenty  per  cent  of  the  fatal 
cases  died  of  "  diphtheritic  croup."  Further  comment  here  is 
unnecessary,  except  to  say:  In  two  instances  prompt  isolation 
saved  all  the  children  so  removed.  During  the  year  ending 
June,  1880,  Illinois  recorded  2,422  deaths  from  diphtheria.  In 
fact,  the  medical  journals  are  constantly  reporting  local  epi- 
demics.~\ 


308  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

In  France  the  real  endemic  condition  makes  the  description 
of  the  epidemics  difficult,  at  least  in  the  large  cities.  There 
are  statistics  from  the  country  where  the  manner  of  appearance 
and  of  propagation  is  easier  to  follow,  the  population  being 
less  dense.  In  1863,  an  epidemic  of  diphtheria  prevailed  at 
Etupes  in  the  district  of  Montbelaird.  Teufferd  gave  an  ac- 
count of  it;  and  in  'j'j  individuals,  17  died  (about  one-fifth). 
The  cases  were  as  numerous  during  the  hot  dry  months  as  dur- 
ing the  damp  cold  months.  The  forms  observed  were  mem- 
branous angina  alone,  and  angina  with  croup.  The  latter  com- 
plication was  always  fatal.  Another  epidemic  raged  during 
the  first  half  of  1862  in  the  parish  of  Ceyret  (Puy-de-D6me). 
It  was  reported  by  Nivet.  It  spread  chiefly  among  children, 
adolescents,  and  the  poorer  population.  No  case  was  seen  in 
persons  over  twenty-five  years  of  age.  Simple  angina  and 
bronchitis  prevailed  during  the  epidemic  in  considerable  propor- 
tion. Guillemant  has  given  in  his  thesis  the  history  of  a  very 
fatal  epidemic  which  broke  out  at  Louhans  (Saone-et-Loire),  in 
October,  1865,  and  continued  till  the  close  of  1865.  In  2,500 
cases  there  were  397  deaths.  Of  these  there  were  1,198  chil- 
dren, and  332  deaths,  that  is,  about  one-fourth.  Females  fur- 
nished 814  cases  of  whom  44  died,  that  is  one  in  18.  There 
were  488  cases  in  men  of  which  21  resulted  fatally,  that  is  about 
one  in  25.  The  epidemic  developed  in  a  sickly  district  of 
countr>',  abounding  in  swamps,  and  turf-pits.  Heavy  fogs  pre- 
vailed during  two-thirds  of  the  year.  The  inhabitants  were 
found  in  a  deplorable  hygienic  condition  ;  they  were  poor,  and 
the  lodgings  and  food  were  unhealthy.  Disease  of  the  potatoes 
and  of  the  vineyards,  rust  of  the  grain,  and  mouldiness  of  the 
leaves  of  the  trees  coincided  with  the  epidemic.  A  short  time 
previously  there  had  appeared  among  the  horses  and  cows  an 
epidemic  characterized  by  a  kind  of  inflammatory  disease  of 
the  mouth  and  throat.  In  man  mediate  contagion  seemed  evi- 
dent. In  another  epidemic  which  scourged  the  community  of 
Fabre"-es  and  of  Saussan,  in  the  southern  part  of  France,  from 
the  latter  part  of  September,  1865,  to  February,  1866,  the  hu- 
midity of  the  atmosphere  appeared  to   Dr.  Gingibre  to   act  an 


LOCALIZATION    OF    DIPHTHERIA.  3O9 

important  part.  In  the  same  year  an  epidemic  prevailed  with 
severity  in  the  district  of  Blaye.  The  first  patient  was  a  strange 
child  which  arrived  with  the  disease,  and  the  second,  a  young  girl 
of  the  same  family.  In  1871,  a  destructive  epidemic  broke  out 
at  Thoury(Loir-et-Cher)  and  was  studied  by  Picard ;  of  2i  at- 
tacked, 9  of  which  were  children,  16  perished.  Other  epidem- 
ics of  the  same  kind  were  signalized  at  Saint-Laurant  de  la 
Pree,  in  which  children  from  three  to  five  years  old  were  at- 
tacked almost  exclusively;  at  Vienna  (Isere)  there  were  12 
tracheotomies,  performed  in  extremis,  giving  only  two  recover- 
ies. In  1872  several  important  epidemics  were  observed:  in 
20  cases  of  diphtheritic  angina,  reported  by  Pantaire  at  Rouelles, 
12  ended  fatally.  Infection  was  very  marked  ;  it  destroyed 
many  by  asphyxia  and  furnished  a  positive  contraindication  to 
tracheotomy.  The  village  is  situated  in  a  damp  valley,  deeply 
enclosed;  the  houses  abutting  towards  the  declivity  of  a. hill, 
received  light  and  air  only  from  one  side.  The  difficulty  of  a 
circulation  of  air  which  results  from  these  conditions  explains 
to  the  observer  the  unusual  gravity  of  the  epidemic.  Conta- 
gion was  seen  very  plainly.  The  city  of  Nogent-le-Roi,  a  short 
distance  from  the  preceding,  was  visited  by  an  epidemic  of 
which  the  account  is  given  by  Flammarian.  From  November 
12,  1871,  to  September  20,  1872,  40  cases  were  observed.  The 
climatic  conditions  were  absolutely  different  from  those  of  the 
surrounding  country.  The  upper  part  of  the  city,  swept  by  the 
wind,  was  alone  attacked.  An  epidemic  which  prevailed  se- 
verely in  the  villages  of  Lizolles  and  Echassiers  gave  opportunity 
for  the  very  interesting  observation  of  a  case  of  paralysis  of  the 
veil  of  the  palate  and  of  the  superior  extremities  which  con- 
tinued six  weeks  in  a  woman  who  had  an  attack  with  only  a 
simple  tonsillitis  without  false  membranes.  It  is  difficult  not  to 
see  in  it  a  case  of  diphtheria  without  exudate.  In  the  neigh- 
borhood of  Arengosse  (Landes)  Malichecq  showed  the  disease 
as  making  its  first  appearance  twelve  years  previously,  then 
becoming  acclimated  and  assuming  at  varied  intervals,  a  course 
clearly  epidemic.  At  the  same  time  diphtheria  appeared  for 
the  first  time  in  the  neighboring  villages ;  importation  seemed 


310  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

to  have  been  the  mode  of  propagation.  Among  the  latter  is 
found  that  of  Sallespisse  (Basses- Pyrenees) ;  as  nearly  all  the 
others,  the  epidemic  which  prevailed  so  severely  in  this  place 
attacked  children  especially.  Of  90  patients  the  children 
numbered  "jj ;  of  20  deaths  they  furnished  19.  Dehee,  ot 
Arras,  has  given  the  history  of  an  epidemic  which  prevailed  in 
the  villages  of  Fampoux  and  Athies  (Pas-de- Calais) ;  of  1,555 
inhabitants,  166  were  attacked,  and  47,  all  children,  perished. 
The  disease  assumed  two  forms :  infectious  and  generalized,  or 
primary  (d'  emblee)  laryngeal  giving  rise  to  asphyxia.  The 
author  considered  the  greatest  intensity  of  the  epidemic  to  co- 
incide with  the  period  of  hauling  manure.  I  have  cited  the 
principal  epidemics  only;  a  great  number  of  others  have  been 
cited,  and  yet  a  less  number  than  have  really  existed.  The  re- 
ports upon  epidemics  published  by  the  Academy  of  Medicine 
give  us  the  following  information  on  the  course  of  diphtheria. 
The  statistics  are  complete  only  from  the  year  1858.  The  num- 
ber of  departments  invaded  were: 

In  1858,  -  -  31  In  1865,  -  -  26 

In  1859,  -  -  40  In  1866,  -  -  23 

In  i860,  -  -  28  In  1867,  -  -  22 

In  1861,  -  -  28  In  1868,  -  -  20 

In  1862,  -  -  26  In  1869-70,  -  -  14 

In  1865,  -  -  22  In  1871,  -  -  20 

In  1864,  -  -  23  In  1872,  -  -  14 

[An  epidemic  still  later  is  reported  by  Sainton.  He  gives 
the  history  of  an  epidemic  which,  from  November  20,  1874,  to 
the  close  of  1875,  prevailed  in  three  communities.  In  the  first 
(Bar-sur-Seine)  in  422  children  from  i  month  to  1 1  years, 
there  were  44  deaths.  In  the  second  (Celles-sur-Ource), 
there  were  16  deaths  in  154  children;  in  the  third  (Mussey- 
sur-Seine),  277  children  were  attacked,  and  20  deaths.  In 
summing  up,  he  gives  the  following  :  5,203  inhabitants,  628  pa- 
tients or  cases,  of  which  80  died.  The  deaths  were  divided  as 
follows:  Boys,  38,  viz.,  '/s;  girls,  n,  viz.,  '/s;  adults,  3,  viz.,  '/ig. 
These  figures  are  incorrect.] 


LOCALIZATION  OF  DIPHTHERIA.  31 1 

In  the  opinion  of  the  reporters  these  figures  are  below  the 
facts:  the  years  1870-71  are,  on  account  of  the  war,  meagre  in 
information.  The  figures  from  the  departments  attacked  give 
only  general  results.  We  should  know  the  number  of  patients. 
All  of  the  reporters  fail  to  give  it. 

In  Belgium,  Dr.  Henroz  reports  that  at  Bihain,  a  village  of 
250  inhabitants,  18  persons  were  attacked  with  membranous 
angina  in  a  few  days  ;  4  of  them  died,  3  of  these  in  the  same 
family.  Gangrene  was  frequent;  haemorrhage  from  the  nose 
and  mouth  was  observed  several  times.  Paralysis  was  constant 
either  with  or  without  ocular  disturbances.  The  larynx  was 
not  attacked.  Holland  and  Northern  Getmany  seem,  accord- 
ing to  published  statistics,  to  have  been  the  favorite  seats  of 
epidemics  of  diphtheria.  In  an  abstract  of  the  various  epidemics 
of  this  nature  which  have  prevailed  in  the  Netherlands,  Van 
Capelle  established  the  fact  that  the  influence  of  unhealthy 
dwellings,  as  well  as  the  contagion  in  the  schools,  have  been 
placed  beyond  question  by  all  writers. 

Dillee,  giving  an  account  of  the  epidemic  of  Arnemuiden, 
declares  that  the  contagion  from  individual  to  individual  was 
evident.  This  epidemic  appeared  in  March,  1864,  in  a  house 
in  which  two  suspected  cases  had  been  noted  in  October,  1 863. 
It  afterwards  extended  to  the  neighboring  houses,  and  attacked 
168  persons  of  the  1,596  inhabitants;  29  died. 

Kohnemann  reports  that,  in  the  island  of  Baltram  on  the 
northern  coast  of  Germany,  in  a  population  of  149  inhabitants 
the  mortality  from  diphtheria  was  12.8  to  the  hundred.  The 
western  village  alone  was  attacked,  while  the  eastern  village, 
situated  at  a  distance  of  fifteen  minutes'  ride,  remained  entirely 
exempt.  Wiedash  infers  from  his  observations  during  the  epi- 
demic of  the  island  of  Nordeney  that  cold  east  winds  and  fogs 
had  a  very  marked  influence  upon  the  development  o'  the  epi- 
demic. He  could  predict  with  certainty  the  outbreak  of  new  cases 
when  this  zveather  prevailed.  Becker  gives  an  account  of  an 
epidemic  which  spread  over  a  district  of  Hanover,  attacked 
153  of  487,  and  destroyed  29.  The  patients  belonged  to  well- 
to-do  families,  to  either  sex  indiscriminately,  and  to  all  ages. 


312  DIPHTHERIA,    CROUP,    AND    TRACHEOTOMY. 

Di]>htheria  of  the  vulva  presented  itself  twice,  without  angina. 
Albuminuria  was  nearly  always  present.  Uhlenburg  observed 
in  the  epidemic  which  occurred  at  Leer  during  the  autumn  of 
1862,  and  which  attacked  more  than  a  hundred  persons,  the  in- 
fluence of  fogs,  which  appeared  to  him  to  favor  the  develop- 
ment of  the  disease.  Contagion  appeared  unmistakable.  Mild 
cases  sometimes  gave  rise  to  grave  ones.  Nevertheless, 
there  were  cases  the  etiology  of  which  remained  obscure. 
Bartels  witnessed  a  large  number  of  cases  of  diphtheria  at 
Kiel  and  its  vicinity.  He  makes  no  distinction  between  croup 
and  diphtheria.  The  disease  developed  by  preference  in  cer- 
tain localities.  Contagion  from  individual  to  individual  could 
not  be  demonstrated  except  in  times  of  epidemics;  but  the 
symptoms  and  complications  of  sporadic  croup  were  the  same 
as  those  of  epidemic  croup.  Only  in  latter  years  has  diphtheria 
attacked  adults  also.  The  gangrenous  form  was  often  ob- 
served after  scarlatina.  Laryngeal  diphtheria  rarely  appeared 
after  this  exanthema.  Croup  secondary  to  measles  was  gener- 
ally benign:  tracheotomy  was  frequently  followed  by  success. 
Croup  consecutive  to  typhoid  fever  appeared  only  recently. 
Albuminuria  appeared  ordinarily  from  the  beginning  of  the  di- 
sease, and  had  no  connection  with  the  asphyxia.  Paralyses 
were  more  rare. 

Denmark.  Lange,  in  his  official  report  on  diphtheria  in 
Denmark  during  the  year  1865,  showed  that  this  disease  as- 
sumed in  a  high  degree  the  epidemic  character,  the  primary 
affection  as  well  as  the  secondary.  The  disease  has  constantly 
advanced  in  the  different  provinces  since  1861. 

We  find  in  1861   -      550  cases.     We  find  in  1864  -  5,987  cases, 
in  1862   -    1,220  cases.  in  1865,    12,826  cases, 

in  1863  -  2,304  cases. 

The  disease  assumed  the  form  of  small  local  epidemics  more 
or  less  intense,  and  without  any  very  apparent  cause.  Their 
course  was  capricious  and  appeared  not  at  all  influenced  by 
the  seasons.  It  was  toward  the  close  of  1865  that  it  attained 
its  maximum  intensity.       It  exhibited    itself  under  two  forms 


LOCALIZATION     OF     DIPHTHERIA.  313 

the  inflammatory  form,  rich  in  false  membranes,  and  causing 
death  by  extension  to  the  larynx  ;  and  the  adynamic  form,  in 
which  the  false  membrane  is  accessory.  Consecutive  paralyses 
were  very  frequent.  According  to  the  opinion  of  every  med- 
ical reporter,  the  disease  was  eminently  contagious ;  but  the 
contagion  does  not  appear  to  them  to  have  been  indispensable 
in  all  cases.  Diphtheria  appeared  to  break  out  spontaneously 
in  flat  and  marshy  countries,  while  it  usually  spared  the  ele- 
vated and  sandy  plains.  Three  years  later,  Ditzel  showed  a 
report  on  an  epidemic  of  diphtheria  submitted  to  his  observa- 
tion in  the  district  of  Frycensbiirg,  during  the  year  1869.  The 
honorable  reporter  notes  a  remarkable  increase  of  cases  of 
croup  and  diphtheria  dunng  later  years.  In  140  cases,  14  suc- 
cumbed, either  from  laryngeal  extension,  or  to  systemic  poison- 
ing. There  was  no  definite  proof  of  contagion.  The  greatest 
number  of  cases  was  observed  during  the  summer  months. 
Both  sexes  were  attacked  in  like  proportions.  The  majority  of 
the  patients  were  between  the  ages  of  five  and  ten  years. 
The  fever  was  often  sthenic  at  the  beginning,  but  in  the  grave 
cases  of  angina  it  assumed  the  asthenic  character.  Convales- 
cence was  always  long  and  followed  by  paralysis,  generally  mod- 
erate. However,  in  126  recoveries  20  were  attacked  with  gen- 
eral paralysis.  Albuminuria  was  without  influence  upon  the 
course  of  the  disease.  The  lymphatic  ganglions  were  never 
tumefied. 

At  Bucharest,  Professor  Felix  gives  the  account  of  a  serious 
epidemic  which,  in  1869-70,  attacted  415  persons  and  destroyed 
200  of  them.  One  very  curious  thing  was  observed:  the  Jew- 
ish population,  amounting  to  1,400  souls,  was  almost  com- 
pletely spared  ficm  the  scourge.  This  immunity  may  be  at- 
tributed, as  it  rccms  to  me,  to  the  customs  of  the  Jews  in  these 
couiitries.  They  live  isolated  in  their  quarter  of  the  city,  con- 
sequently under  the  most  favorable  conditions  to  avoid  con- 
tagion. 

\Roiiinania.  In  1879  Droumoff  took  for  the  subject  of  a 
thesis  the  account  of  an  epidemic  of  diphtheritic  angina  which 
prevailed  in  Roumania  in  the  district  of  Braila.      Another  epi- 


314  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

demic  prevailed  at  Florence  and  vicinity  from  1862  to  1872,  re- 
ported by  Drs.  Morelli  and  Nesti  in  1875. 

Luconi  observed  in  1875,  1876,  at  Veroli,  a  province  of 
Frosinone  {L'alj),  an  epidemic  in  which  the  great  humidity  of 
the  summers  of  1875- 1876  appeared  greatly  to  augment  the 
gravity  of  the  disease.  The  author  has  noted  a  certain  num- 
ber of  cases  of  diphtheria  without  diphtheria  (diphtheric  sans 
diphtheric.)     These  statements  give  the  following  results  : 

AGE.  SEX,  MALE.  SEX,  FEMALE.  RECOVERIES.      DEATHS. 

2  to  10  years  -  -  124  115  194  45 

10  to  16  years  -  -  37  44  7^  9 

16  to  30  years  -  -  19  22  33  8 

30  to  40  years  -  -  II  7  14  4 

191       188       313       66 

The  same  author  witnessed  an  epidemic  of  like  nature  in 
1873,  which  caused  a  mortality  of  one  inhabitant  in  five. 

The  Russian  journals  publish  terrible  details  of  the  diph- 
theria now  epidemic  in  Russia.  It  is  reported  that  in  certain 
communes  and  parishes  all  the  children  under  15  years  old 
have  died.  The  origin  of  the  attack  dates  from  1872,  when  the 
disease  first  appeared  in  Bessarabia.  Since  then  it  has  spread 
far  and  wide  over  the  south  of  the  Empire,  whence  it  lately 
began  to  make  rapid  progress  toward  the  east  and  northwest. 
In  Pultawa,  a  province  of  considerably  less  than  2,000,000 
inhabitants,  there  have  been  45,543  cases,  of  which  18,765 
were  fatal,  one  in  about  two  and  a  half.— Med.  Rec.  1881.] 

Southern  Germany.  Leopold  Graf  gives  a  statistical  state- 
ment of  24  cases  of  diphtheria,  7  of  which  terminated  in  death. 
Contagion  was  fully  demonstrated  in  9  cases.  There  was  al- 
buminuria in  one-half  of  the  patients.  In  two  cases  autopsy 
revealed  suppurative  nephritis.  Dr.  Gaupp  observed  from  1865 
to  1866  a  limited  epidemic  at  Schorndorf  in  Wiirtemberg.  Of  66 
patients  there  were  23  deaths.  Tracheotomy  was  not  performed 
because  of  the  preponderance  of  adynamia.  Contagion  was 
clearly  established.     A.  Mair,  in  his  report  on  the  epidemics  of 


LOCALIZATION    OF    DIPHTHERIA.  315 

Middle  Franconia  for  the  year  1868,  states  that  contagion  was 
recognized  by  all  observers.  Incubation  lasted  on  an  average 
from  eight  to  ten  days ;  in  certain  cases  it  was  from  four  to  six 
weeks. (?)  Relapses  (recidives)  were  frequent.  Complications 
on  the  part  of  different  organs  were  quite  common.  Death 
usually  occurred  by  asphyxia. 

Sxvitzerland.  Croup,  in  Geneva,  has  had  for  a  long  time  a  special 
physiognomy  which  caused  it  to  be  regarded  by  all  older  au- 
thors as  a  local,  inflammatory  and  spasmodic  affection  of  the 
larynx.  Vieusseux  and  Jurine,  who  described  pseudo-mem- 
branous bronchitis  and  laryngitis  have  almost  never  observed 
membranous  angina.  While  admitting  an  epidemic  influence 
in  the  development  of  croup,  they  have  denied  contagion. 
Nevertheless,  an  epidemic  of  malignant  diphtheria  was  ob- 
served by  Baup  of  Nyon,  in  1826.  The  author  admitted  fully 
that  diphtheria  is  a  general  disease  capable  of  being  produced 
in  different  organs,  viz.,  the  ears,  the  anus,  genital  organs,  and 
inferior  extremities,  localizations  to  which,  following  the  ideas 
of  that  date,  he  gave  the  name  of  spontaneous  gangrene.  Ex- 
cept this  account,  authors  are  in  accord  as  to  the  rarity  ol 
membranous  angina  at  Geneva,  up  to  these  latter  years.  Dr. 
Mark  D'Espine,  in  his  remarkable  work  on  mortuaiy  statistics, 
which  embrace  thirteen  years  of  careful  compilation  of  facts  at 
Geneva  from  1838  to  1847,  and  from  1853  to  1855,  was  able  to 
note  but  twenty  cases  of  membranous  angina  in  266  deaths 
from  croup  carefully  analyzed.  The  disease  attacked  children 
principally,  from  I  to  3  years  old.  The  frequency  of  croup 
was  particularly  apparent  during  winter,  next  during  autumn ; 
next  following,  spring  and  summer.  The  activity  of  the  disease 
predominated  in  a  marked  degree  upon  the  male  sex.  The  in- 
fluence of  social  conditions  appeared  to  be  nil.  Tracheotomy 
was  performed  during  these  thirteen  years  only  eight  times, 
and  without  success.  According  to  a  communication  which 
Dr.  D'Espine,  Jr.,  kindly  made  to  me,  membranous  angina  has 
become  for  some  years  more  frequent  at  Geneva  ;  and  croup 
has  also  there  assumed  more  frequently,  the  infectious  char- 
acter.    But  exact  information  in  this  respect  is  wanting 


3l6  DIPHTHHRIA,    CROUP    AND    TRACHEOTOMY. 

[In  1876  the  deaths  from  diphtheria  for  the  whole  of  Switz- 
erland were  14  to  1,000  total  deaths.] 

I  shall  close  this  review  by  giving  the  opinion  of  two  writers 
who  have  compared  notes  of  several  epidemics  occuring  in  dif- 
ferent countries  : 

A.  Hirsch,  in  his  Manual  of  Medical  Geography,  arrives  at 
the  following  conclusions :  "A  glance  over  the  historical  de- 
velopment and  the  geographical  distribution  of  diphtheria  jus- 
tifies the  conclusion,  that  climatic  circumstances  exert  no  es- 
sential influence  on  the  genesis  of  the  disease.  Seasons  have 
no  marked  influence,  since,  of  109  epidemics  of  malignant 
angina  36  occurred  in  the  spring,  20  in  summer,  26  in  autumn, 
and  27  in  winter." 

Kieser  is  of  the  opinion  that  diphtheria  is  propagated  at  one 
time  by  contagion,  at  another  by  miasmatic  influences.  He 
classes  the  epidemics  of  these  latter  years  as  follows : 

FIRST CONTAGIOUS    EPIDEMICS. 

Christiania,  1 861- 1864         -         -         -         - 
Louhans,  1863- 1865         -         -         -         -         - 
Arnemuiden,  March  1864  to  July  1865 
Kleverswerke  (Holland)  _         _         _         _ 

Rossum,  July  1864  to  August  1865     -         -         -      ... 
Sweden,  1861-1862  -         -         -         -         -  ... 

SECOND EPIDEMICS    ALMOST    EXCLUSIVELY    MIASMATIC. 

CASES.      DEATHS. 

Schleswig-Holstein,  1862-65  -         -         _  10,759      1.63 1 

Lisbon,  1859  i860   ------     10,759      1,631 

THIRD — EPIDEMICS    EXCLUSIVELY    MIASMATIC. 

CASES.      DEATHS. 

District  of  Bordesholm  (Holstein),  1859-65       -         247 
Namdalen  (Norway),  1859-61        _         _         _         .     247  23 

Cases  described  by  Luzinsky  at  Vienna,  1866,  247  23 

This  statement,  as  one  sees,  gives  predominance  to  conta- 
gion. T.iis  epidemiological  review  will  furnish  us  the  materials 
for  solving  the  following  questions  : 

First — How  do  epidemics  of  diphtheria  originate? 

Second — An  epidemic,  once  created,  how  does  it  spread  ? 


CASES. 

DEATHS 

361 

76 

2,500 

367 

169 

29 

ARTICLE  FIRST— ORIGIN  OF  EPIDEMICS. 


Epidemics  of  diseases  manifestly  infectious,  such  as  cholera, 
yellow  fever,  and  typhus  fever,  reveal  nearly  always  as  a 
starting  point  the  importation  of  disease  germs,  either  by  one 
or  more  contaminated  persons,  or  by  objects  which  had  been 
in  a  center  of  infection.  Every  one  knows  the  history  of  these 
epidemics  following  the  arrival  in  a  port,  till  then  perfectly 
healthy,  of  a  ship  having  on  board  patients  sick  of  yellow 
fever  or  cholera :  we  do  not  forget  those  which  suddenly  break 
out  in  places  isolated  from  every  center  (foyer),  the  origin  of 
which  was  due  to  the  arrival  of  a  contaminated  individual  or  a 
trunk  of  clothes  and  linen  which  had  belonged  to  the  patient. 
The  same  investigations  have  been  made  respecting  epidemics 
of  diphtheria,  and  have  often  been  crowned  with  success. 
Omitting  the  large  cities  in  which  the  starting  point  is  often 
difficult  to  find,  country  places  and  villages  frequently  present 
most  valuable  information.  Bretonneau,  Trousseau,  and  phy- 
sicians who  have  made  observations  in  the  country,  have  given 
numerous  and  striking  examples  of  it.  One  of  the  most  re- 
markable was  furnished  by  Bonnet.  A  young  girl  of  i6  years, 
was  taken  with  diphtheritic  angina  in  a  village  in  which  this 
disease  prevailed.  She  went  immediately  to  her  parents,  in  a 
community  about  four  m^les  distant  which  had  never  been  vis- 
ited by  membranous  angina,  A  few  days  later,  this  latter  lo- 
cality was  invaded  by  the  epidemic ;  the  young  girl  who  had 
brought  it  died,  communicating  the  disease  to  her  sister,  who 
also  died.  The  father,  alarmed,  went  to  a  village  about  three 
miles  distant  to  escape  the  scourge,  but  he  died  at  the  end 
of  nine  days,  leaving  angina  to  ravage  the  county  to  which  he  had 
come  to  seek  a  refuge.  We  cannot  find  a  demonstration  more 
striking  of  the  power  that  diphtheria  possesses  of  transmitting 

(V7) 


3l8  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

itself  by  importation.  Without  going  so  far,  do  we  not  fre- 
quently see  a  patient,  affected  with  diphtheria,  infecting  the 
ward  of  a  hospital  or  the  entire  establishment?  We  have  not 
always,  it  is  true,  at  hand  data  equally  certain;  we  are  very 
often  compelled  to  remain  in  ignorance  of  the  cause  of  an  epi- 
demic. But  do  we  not  see  other  infectious  diseases  acting  the 
same  way?  Typhoid  fever,  for  example,  a  disease  essentially 
epidemic  and  infectious,  sometimes  forms  foci,  which  suddenly 
break  out  in  certain  regions  without  it  being  possible  to  trace 
back  its  origin.  In  large  cities  in  which  typhoid,  measles, 
scarlatina,  variola,  etc.,  are  in  an  endemic  state,  silence 
concerning  the  cause  is  not  surprising.  It  is  no  longer  a  new 
epidemic  which  appears,  but  an  aggravation  of  an  epidemic 
already  existing.  In  circumscribed  localities,  when  the  epi- 
demic appears  for  the  first  time,  the  explanation  is  more  diffi- 
cult to  furnish.  Then  it  is  the  question  maybe  asked,  whether 
diphtheria  has  not  the  power  of  developing  spontaneously, 
whether  an  individual  not  exposed  to  miasma  may  not  himself 
engender  the  disease.  No  fact  gives  foundation  to  this  view.  It  is 
better  to  admit  the  ingenious  theory  of  Trousseau  on  the  latency 
oigerms  (le  sommeil  des  germs).  "These  miasmata,  principles, 
germs,  the  name  given  them  is  of  little  importance,"  says  the 
distinguished  teacher,  "may  remain  latent,  dormant,  for  a 
greater  or  less  length  of  time,  buried  in  inorganic  substances; 
then  at  a  certain  time  under  certain  electrical  or  atmospheric 
conditions  which  we  do  not  understand  either,  but  of  which  no 
one  denies  the  influence,  they  develop  themselves,  to  attack 
those  who  are  found  susceptible  to  receive  them."  They  may 
remain  latent  for  months  or  years,  in  clothing,  tapestry,  etc.  of 
apartments,  awaiting  conditions  which  favor  their  germination. 
Take  for  example  variola.  An  individual  is  attacked  with  the 
disease.  He  had  not  been  in  communication  with  any  small- 
pox patient.  But  has  he  not  suffered  the  contact  of  contam- 
inated clothing?  has  he  not  stayed  in  a  place  occupied,  per- 
haps at  some  previous  time,  by  a  variolous  patient?  Science 
is  rich  in  facts  which  furnish  argument  in  favor  of  this  view. 
These  facts   are  applicable   in  every  respect  to  diphtheria,  and 


LOCALIZATION    OF    DIPHTHERIA.  3I9 

may  refer  to  the  origin  of  epidemics  which  appear  to  be  spon- 
taneous. The  origin  of  epidemics  of  diphtheria  may,  there- 
fore, very  Hkely  be  explained,  in  the  first  place,  by  the  importa- 
tion of  morbific  germs  into  a  healthy  country,  whether  the  car- 
rier has  been  attacked  with  the  well-marked  disease,  or  whether 
he  comes  from  another  country  with  the  poison  germs  remain- 
ing for  a  long  time  in  a  latent  state  in  his  clothing  or  in  ar- 
ticles of  contaminated  furniture;  in  the  second  place,  by  bring- 
ing into  new  activity  germs  connected  with  a  former  epidemic 
which  remained  dormant  for  a  longer  or  shorter  period.  This 
doctrine  of  importation  accounts  for  a  fact  which,  for  some 
years,  has  struck  every  obsen^er,  I  mean  to  speak  of  the 
invasion  of  many  countries  by  diphtheria  in  which  it  had  never 
been  known.  Notably  in  France,  diphtheria  was  confined 
during  a  long  time  to  certain  departments  of  the  interior.  At 
Paris  diphtheria  has  been  observed,  for  only  quite  a  limited 
number  of  years,  since  the  epidemics  of  1842-43  described  by 
Boudet  and  Becquerel.  It  disappeared  again  for  a  long  inter- 
val;  it  was  seen  no  more,  really,  till  1855.  It  then  returned  in 
epidemics,  and  afterwards  ended  by  establishing  itself  endemic- 
ally.  The  epidemic  of  1855,  which  was  the  signal  of  the  final 
invasion,  was  coincident  with  the  important  developments 
made  in  the  means  of  communication  in  all  Europe,  and  in 
France  particularly.  Paris  became,  in  large  measure,  the 
place  of  attraction  for  the  whole  world.  It  is  not  surprising 
that  epidemics,  previously  limited  to  certain  points  in  France 
or  other  countries,  should  have  been  imported  into  the  capital. 
Cholera  furnishes  us  an  example  of  the  same  kind.  Its  recent 
outbreaks  have  spread  throughout  all  Europe  with  a  rapidity 
unknown  to  those  which  preceded  the  extension  of  rapid  com- 
munication. Compari.'^on  of  the  epidemics  of  1832  and  1849 
with  those  of  1855  and  1866  leave  no  doubt  in  this  respect. 
Everything  proves  that  diphtheria  has  been  affected  by  the 
same  influences.  In  many  places  in  France  statements  from 
physicians  agree  respecting  the  coincidence  between  the  ar- 
rival of  diphtlieria  and  the  estalishment  of  railroads  in  their 
localities.     Until  then   they   had  known   this  disease  only  by 


320  DIPHTHERIA,  CROUP    AND    TRACHEOTOMY. 

name.  The  diffusion  of  germs  by  the  introduction  of  rapid 
transit,  and  by  the  active  travel  which  results  from  it,  appeared, 
therefore,  to  be  the  cause  of  the  extension  of  diphtheria.  Ad- 
mitting the  morbific  principle,  the  spores  existing  for  a  long 
time  in  a  locality,  and  remaining  torpid,  what  are  the  condi- 
tions which  preside  over  their  revivification  ?  The  solution  of 
this  question  would  enable  us  to  know  under  what  circum- 
stances epidemics  have  their  origin.  We  must  recognize  the 
fact  that  in  this  matter  science  is  richer  in  theory  than  in  ex- 
act data.  According  to  the  majority  of  authors  climatic  con- 
ditions have  considerable  importance.  Since  Home,  all  ob- 
servers have  reiterated  that  croup  had  a  great  tendency  to  de- 
velop in  low  damp  localities.  Among  the  modern  epidemics 
which  I  have  cited,  several  appear  to  have  been  influenced  by 
humidity ;  such  are  those  of  Louhans,  Nordeny  and  Leer. 
Among  former  ones  we  may  mention  that  of  La  Chapelle 
Veronge,  described  by  Dr.  Ferrand  as  well  as  those  of  which 
Drs.  Gendron  and  Orillard  are  the  reporters.  But  in  addition 
to  these  observers,  several  among  the  modern  ones,  like  Ditzel, 
and  others  older,  to  the  number  of  which  must  be  added 
Bouillon  Lagrange,  have  been  placed  under  different  circum- 
stances. 

*'I  have  observed  this  disease,"  says  the  latter,  "under  the  most  opposite  condi- 
tions, on  elevated  planes,  and  in  small,  dark  valleys,  moist  even  in  the  midst  of  gen- 
eral dryness,  in  the  heat  as  well  as  in  the  cold.  During  the  entire  continuance  of  the 
epidemic  the  dryness  of  the  atmosphere  was  extraordinary,  and  for  persistency,  such 
as  had  not  been  seen  for  many  years,  the  reverse  of  what  had  been  observed  in  pre- 
vious epidemics   of  which  humidity  seemed   to   be  the  principal  condition." 

Several  authors  have  found  the  influence  of  season  nil ;  and 
diphtheria  according  to  them,  appeared  at  all  seasons,  viz., 
Tuefferd,  Lange  and  Kohnemann.  Hence,  diphtheria  may 
arise  in  all  climates  as  the  statements  of  Hirsch  prove,  and  in 
every  meteorological  condition.  Yet  epidemics  coincident 
with  hot,  dry  seasons  are  exceptional,  and  they  prove  but  one 
thing,  that  is,  that  atmospheric  influence  is  but  a  factor  not  in- 
dispensable in  the  etiology  of  diphtheria.  On  the  contrary, 
damp  seasons  and   fogs   seemed,   in  the  majority   of  cases,  to 


LOCALIZATION    OF     DIPHTHERIA.  321 

favor  remarkably  the  development  of  the  epidemic.  That  of 
Louhans  is  very  interesting  in  this  respect ;  the  moisture  had  at- 
tained to  its  maximum  in  the  country  ;  it  rotted  the  crops,  and 
mildewed  the  leaves  on  the  trees.  That  in  the  island  of  Nor- 
deney  is  still  more  striking.  Roger  and  Peter  also  admitted 
the  influence  of  cold  and  moisture  on  the  generation  of  diph- 
theria. The  statistics  of  cases  observed  at  the  Hospital 
"  Sainte  Eugenie  "  for  twenty  years,  in  the  service  of  Barthez, 
added  to  those  of  my  private  practice,  furnish  me  the  follow- 
ing results  : 

Of  1,568  cases,  the  month  of 

Brought  forward,     -     874 

January  furnishes     -     -     160     July  furnishes     -     -     -  119 

February  furnishes  -     -     157     August  furnishes,    -     -  113 

March  furnishes  -     -     -     153      September  furnishes  -  82 

April  furnishes     -     -     -     144     October  furnishes    -     -  124 

May  furnishes      -     -     -     152     November  furnishes     -  122 

June  furnishes      -     -     -     108     December  furnishes     -  234 


Carried  foward      -      874  Total      .     -     -     -      1,568 

The  figures  which  this  table  presents  to  us  assign  the  max- 
imum of  frequency  to  that  part  of  the  year  from  January  to 
May  inclusive.  From  January  there  is  an  imperceptible  de- 
crease to  August,  and  it  then  suddenly  falls  in  September  to  a 
decided  minimum.  The  increase  begins  in  October,  and  pro- 
gresses rapidly  in  December.  The  following  comparative 
table,  arranged  from  figures  furnished  by  E.  Besnier  for  the 
commission  on  prevalent  diseases,  presents  the  variations  of 
croup  in  the  hospitals  of  Paris  during  the  period  extending 
from  1868  to  [1880,  eleven  years.  I  here  insert  a  more  com- 
prehensive table  answering  other  purposes  as  well,  from  a 
more  recent  article  by  the  same  author]  except  the  years  1870- 
71  which  furnish  only  incomplete  statistics: 


322 


DIPHTHERIA,  CROUP    AND    TRACHEOTOMY. 


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LOCALIZATION    OF    DIPHTHERIA. 


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324  DIPHTHERIA,    CROUP  AND    TRACHEOTOMY. 

The  results  vary  slightly :  the  maximum  is  found  in  March, 
and  the  minimum  in  September,  The  difference  observed  in 
these  two  tables  may  pertain  to  the  fact  that  the  first  contains 
diphtheria  in  all  its  forms  from  that  of  the  pharynx  to  that  of 
the  skin,  conjunctiva,  etc.,  while  the  second  is  limited  to 
croup. 

Influence  of  other  Epidemics. — May  an  epidemic  of  another 
kind  be  the  agent  in  causing  the  germ  of  diphtheria  to  spring 
up  ?  The  frequent  coexistence  of  epidemics  of  scarlatina  and 
of  measles  with  those  of  diphtheria  has  been  noted.  We  know 
that  these  diseases  frequently  occasion  secondary  diphtheria. 
But  there  is  nothing  to  prove  at  this  date  that  they  have  the 
power  to  originate  epidemics  of  diphtheria  ;  they  may  be  con- 
sidered as  agents  which  in  times  of  epidemics,  present  to  the 
morbific  germ  a  prepared  soil;  this  is  the  limit  of  their  influ- 
ence. In  connection  with  the  epidemic  of  Louhans,  Guillemont 
has  brought  to  light  an  interesting  fact.  An  epizootic  preceded 
the  epidemic  ;  it  consisted  of  an  inflammatory  disease  of  the 
mouth  and  throat  in  cows  and  horses. 


ARTICLE  SECOND— DEVELOPMENT  OF 
EPIDEMICS. 


By  virtue  of  previous  causes,  or  by  the  action  of  others  which 
remain  unknown,  one  or  more  cases  of  diphtheria  have  broken 
out  in  a  country  exempt  for  a  period  of  greater  or  less  length. 
By  what  series  of  events  do  they  constitute  an  epidemic  ?  In 
every  disease  which  assumes  the  epidemic  type  we  must  con- 
sider two  factors,  the  morbific  germ  and  the  organism  with 
which  it  is  found  in  contact.  The  conditions,  therefore,  which 
favor  the  development  of  an  epidemic  are,  on  the  one  hand 
those  which  maintain  the  vitality  of  the  germ  and  preserve  to 
it  its  germinating  power,  on  the  other,  those  which  render  the 
organism  susceptible  of  being  impregnated.  There  is  another 
important  point,  the  study  of  which  should  be  undertaken  be- 
fore that  of  the  preceding,  that  is,  the  intimate  mechanism  by 
virtue  of  which  diphtheria  is  transmitted  from  individual  to  indi- 
vidual. 

§   I.    THE    MODE    OF    TRANMISSION    OF    DIPHTHERIA. 

Spontaneous  development  not  being  recognized,  until  evi- 
dence of  the  contrary  as  one  of  the  attributes  of  this  disease, 
contagion  appears  to  be  its  most  probable  mode  of  trans- 
mission. 

I.    CONTAGION    IN    DIPHTHERIA. 

In  order  to  avoid  all  confusion  it  is  important  to  state  defi- 
nitely the  meaning  which  I  give  to  this  term.  It  really  appears 
to  prejudge  the  question  and  to  imply  the  necessity  of  contact 
between  individuals.  Now,  transmission  by  contact  alone  be- 
ing sharply  contested,  many  authors  justly  consider  the  word 
improper.  By  this  standard  it  should  be  excluded  from  no- 
sology. Yet  it  is  in  such  constant  use  that  it  may  be  preserved 

(325) 


326  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

on  condition  that  an  acceptable  meaning  be  assigned  to  it.  It 
may  be  understood,  I  think,  in  the  sense  of  tra)ismissibility 
from  individual  to  individual  with  or  without  a  medium.  While 
indicating  the  capability  which  this  disease  possesses  of  being 
transmitted  from  one  person  to  another,  this  term  reserves  the 
mechanism  by  which  the  communication  is  effected.  In  this 
sense,  contagion  is  admitted  by  most  authors.  Denied  by 
Home,  Michaelis,  Vieusseaux,  Jurine,  and  Albers  of  Bremen,  it 
has  been  admitted  by  Wichmann,  Bohmer,  Field,  Rosen, 
Guersant,  Bretonneau,  and  Trousseau.  The  majority  of  physi- 
cians who  have  observed  epidemics,  or  who  have  written,  for 
some  years  past,  on  diphtheritic  angina  or  croup,  hold  it  as 
demonstrated.  I  fully  adopt  this  view.  The  transmission  of 
diphtheria  may  be  accomplished  by  three  modes:  First,  by 
direct  contact ;  second,  by  inoculation ;  third,  by  the  atmosphere 
(ambient  air.) 

II.     TRANSMISSION    BY    DIRECT    CONTACT. 

Numerous  facts  have  been  invoked  in  favor  of  this  mode  of 
communica  ion.  Physicians  in  nearly  every  case,  have  fur- 
nished the  proof  at  their  own  cost.  Herpin  of  Tours,  Gendron, 
Blache,  Jr.,  Gillette,  Valleix,  Weber,  and  many  others  were 
poisoned  by  the  morbid  products  expelled  from  the  diphthe- 
ritic patient,  into  the  mouth,  onto  the  lips,  and  into  the  nose. 
These  facts  have  furnished  too  large  a  number  of  reports  to  be 
repeated  here  in  detail.  Let  me  say  in  few  words,  that  Herpin, 
while  cauterizing  the  throat  of  a  child  attacked  with  diphthe- 
ritic angina,  received  into  the  left  nostril  a  spurt  of  the  morbid 
matter.  Some  hours  afterwards  there  was  closure  of  the  left 
nostril,  snuffling,  dysphagia,  and  the  next  day  membranous 
patches  were  spread  over  the  tonsils  and  the  uvula.  On  the 
latter  the  membrane  reproduced  itself  three  times.  Diphthe- 
ritic paralysis  terminated  the  attack;  but  he  finally  recovered. 
Valleix  contracted  diphtheria  under  similar  circumstances. 
A  patient  afflicted  with  membranous  angina,  not  serious, 
however,  and  who  recovered,  threw  into  his  mouth  a  little 
saliva   during   an  effort  of  coughing  caused  by  examining  the 


DEVELOPMENT    OF    EPIDEMICS.  32/ 

throat.  The  next  day  one  of  the  tonsils  was  covered  with  false 
membranes;  very  soon  the  other,  the  uvula,  and  the  nasal  fossae 
were  attacked.  Considerable  submaxillary  engorgement 
arose,  cerebral  symptoms  appeared,  and  death  occurred  in  for- 
ty-eight hours  without  laryngeal  symptoms.  Blache  Jr.  con- 
tracted diphtheria  under  similar  circumstances  and  died. 
Gendron  of  Chateau-du-Toire,  during  the  operation  of  tra- 
cheotomy, at  the  moment  of  opening  the  trachea,  received  a 
shower  of  particles  of  false  membrane,  some  of  which  fell  on 
his  lips.  An  attack  of  diphtheritic  angina  was  the  result  of 
this  accident.  The  martyrology  of  science  contains  yet  many 
other  victims. 

[Dr.  Andres  Arango  y  Lamar,  Havana.  St.  Louis  Med. 
and  Surg.  Jour.  XLV(i883),  p.  569.  M.  Reverdy,  assistant  to 
Dr.  Bouchut  at  Paris.  Med.  Rec.  N.  Y.  XVII.  302.  (1880). 
Dr.  Wilbur  F.  Sandford,  Greenpoint,  N.  Y.  XIX  (1881).  Dr. 
Samuel  Rabbeth.  London,  Eng.  N.  Y.  Med.  Rec.  XXVI 
p.  521,  550.  (1884).] 

Prof.  See  has  communicated  to  the  Societe  des  Hopitaux 
a  very  curious  incident.  A  woman  was  nursing  a  child  (not 
her  own)  attacked  with  diphtheritic  angina  ;  though  the  nipples 
remained  sound,  her  own  child  which  she  continued  to  suckle, 
contracted  a  labial  diphtheria  and  communicated  it  to  its 
mother  who  had  not  abstained  from  kissing  it.  Presented  as 
an  example  of  inoculation,  this  case  may  be  attributed,  strictly 
speaking,  to  direct  contact.  We  may  apply  direct  contact  in 
explanation  also  of  the  following  incident:  A  child  of  two 
years  of  age  is  attacked  with  grave  diphtheritic  coryza ;  it  is 
deemed  proper  to  apply  a  blister  to  the  nape  of  the  neck,  and 
the  blistered  surface  immediately  becomes  covered  with  false 
membranes.  The  child  dies.  Like  many  sick  children  this 
one  demanded  that  the  father  or  mother  should  carry  it  con- 
stantly in  their  arms.  In  this  position  the  nose  was  frequently 
brought  in  contact  with  that  of  the  person  holding  it.  After 
its  death  both  parents  were  attacked  with  diphtheritic  coryza. 
Against  these  examples  may  be  presented  the  negative  result 
of  experiments  made  by  Peter.     In  one,  this  courageous  phy- 


328  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

sician  having  received,  during  a  tracheotomy,  a  semi-Hquid 
false  membrane  upon  the  left  conjunctiva  let  it  it  remain  under 
the  lid,  and  experienced  no  unpleasant  result  from  it.  In 
another,  he  dipped  a  hair  pencil  into  a  soft  false  membrane 
ejected  during  an  operation  and  painted  his  tonsils,  the  soft 
palate,  and  the  pharynx  with  the  pencil ;  the  result  was  nil, 

Duchamp  obtained  a  similar  result  by  repeating  these  two 
experiments.  Fortunately,  by  chance  these  trials  had  no  bad 
result,  but  they  do  not  prove  that  direct  contact  will  be  without 
inconvenience ;  their  small  number  even  prevents  them  from 
being  conclusive.  Repeated  a  large  number  of  times  they 
might  produce  results  quite  different;  what  they  really  demon- 
strate is  that  direct  contact  does  not  necessarily  transmit 
diphtheria.  That  is  a  fact  common  with  all  contagious  dis- 
eases, even  in  inoculable  ones ;  they  are  not  propagated  in 
every  case  by  these  methods.  In  these  experiments  two  facts 
must  always  be  considered,  the  seed  and  the  soil.  The  soil 
may  be  unsuited  to  the  germ,  its  receptivity  nil ;  the  germ 
which  sprang  up  in  another  soil,  dies  in  this.  But  if  the  ob- 
jections formed  from  the  experiment  of  Peter  are  not  conclu- 
sive, there  is  still  another  which  extends  farther.  It  may  be 
said,  persons  in  whom  we  see  false  membranes  develop  under 
the  pretended  influence  of  direct  contact,  are  living  with  the 
patients,  or  like  physicians,  visit  them  once  or  oftener  daily, 
and  are  thus  exposed  to  transmission  by  inhalation.  That 
is  a  strong  objection  ;  it  may  be  true  in  a  certain  number  of 
cases  attributed  to  contact.  Nevertheless,  it  is  difficult  not  to 
invoke  this  cause  in  the  cases  in  which  the  false  membrane 
occurs  at  exactly  the  point  brought  in  contact  with  the  morbid 
product.  To  these  arguments  must  be  added  that  one  coming 
from  experiments  on  animals.  The  first  series  was  made  by 
Trendelenburg.  Patches  of  pseudo-membrane  from  children 
affected  with  croup  were  introduced  into  the  trachea  of  rab- 
bits and  pigeons.  In  sixty-eight  operations,  eleven  gave  rise 
to  evident  diphtheritic  manifestations;  the  lesions  were  the  same 
as  in  man.  The  animals  succmbed,  usually,  to  asphyxial 
croup.     The  disease  required  twenty-four,  forty-eight   or  sev- 


DEVELOPMENT    OF    EPIDEMICS.  329 

enty-two  hours  to  develop.  Then  taking  the  false  membranes 
obtained  from  these  animals,  the  author  applied  them  to  a 
second  series  of  subjects:  he  again  obtained  several  positive 
results.  Control-experiments  were  made  by  placing  in  the 
larynx  of  other  animals  some  irritant  or  putrid  substances  ; 
catarrh  of  the  mucous  membrane  and  abscesses  were  oc- 
casioned, but  never  true  pseudo-membranes.  Diphtheria  of 
the  pharynx,  followed  by  descending  croup,  was  never  ob- 
tained. Oertel  of  Munich,  with  this  purpose,  undertook  three 
series  of  experiments. 

In  the  first  series  he  produced  by  means  of  chemical  irritants, 
viz.,  ammonia,  etc.,  an  artificial  croup  identical  in  its  lesions 
and  symptoms  with  human  croup,  He  never  found  at  the  au- 
topsy other  organs  inflamed  ;  the  kidneys  especially  were  per- 
fectly normal  ^7.r«  after  prolonged  asphyxia.  Experiments  of 
inoculation  made  with  false  membranes  from  these  animals  were 
always  negative.  In  the  second  series,  he  introduced  into  the 
trachea,  larynx  and  upon  the  tonsils  of  twelve  rabbits,  frag- 
ments of  diphtheritic  false  membrane  from  man.  Five  died  by 
suffocation  and  three  by  general  toxaemia.  At  the  autopsy  besides 
the  pseudo  membranous  inflammation  of  the  larynx  and  trachea, 
he  found  capillary  haemorrhages  disseminated  in  many  of  the  or- 
gans, and  a  decided  hyperaemia  of  the  kidneys.  The  application 
being  made  in  the  same  manner  to  other  animals,  the  false  mem- 
branes obtained  in  the  first  of  them  were  reproduced  two  or 
three  times  successively.  In  the  third  series,  similar  inocula- 
tion experiments  tried  with  ordinary  putrid  substances  gave  rise 
to  results  absolutely  different.  Labadie  Lagrave  introduced 
into  the  larynx  and  trachea  of  two  rabbits,  false  membranes  re- 
cently expelled  by  children  affected  with  croup,  by  performing 
upon  these  animals  a  preliminary  tracheotomy  followed  by  in- 
troducing into  the  trachea  a  soft  rubber  catheter  of  5  centime- 
tres diameter  used  as  a  cannula.  The  false  membrane  previously 
diluted  and  mixed  in  a  mortar  was  introduced  by  means  of  a 
curved  forceps,  directly  into  the  cavity  of  the  larynx,  in  the  first 
animal  and  simply  deposited  in  the  trachea  in  the  second. 
About  twelve  hours  after  the  operation,  both  the  rabbits  hav- 


330  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

ing  died  from  asphyxia,  false  membranes  were  found  in  a  state  of 
organization  in  the  larynx  of  the  first,  and  in  the  trachea  of  the 
second,  occupying  quite  a  large  surface,  and  the  mucous  mem- 
brane about  the  three  centremetres  below  it  was  red,  thicken- 
ed, ulcerated,  and  contained  a  rich  vascular  network. 

Duchamp  resumed  the  experiments  under  the  same  condi- 
tions. False  membrane  previously  washed,  then  triturated, 
was  introduced  into  the  trachea  and  larynx  of  a  tracheotomized 
rabbit  with  a  hair  pencil,  care  being  taken  not  to  bring  it  in 
contact  with  the  margins  of  the  wound.  The  animal  died  at 
the  end  of  forty-eight  hours,  and  the  autopsy  revealed  the  mu- 
cous membranes  of  the  larynx  and  trachea  covered  with  false 
membranes,  which,  examined  under  the  microscope,  showed 
exactly  the  characters  of  those  of  the  child.  The  air  passages 
were  the  seat  of  an  intense  inflammation;  the  lower  lobes  of  the 
lungs  were  hepatized. 

A  trial  made  with  products  found  four  days  after  death  in  the 
trachea  of  a  child  dead  of  croup,  gave  only  negative  results. 
Besides,  these  products  had  no  longer  the  pseudo-membranoiis 
appearance  ;  they  consisted  of  leucocytes,  mobile  and  refract- 
ing granules,  and  elongated  and  ovoid  spores.  This  series  of 
experiments  proves  most  fully  the  transmissibility  of  diphthe- 
ria by  contact.  Most  authors  find  here  also  proof  of  inocula- 
bility,  but  the  exact  meaning  of  inoculability  implying,  it  seems 
to  me,  the  deposit  of  morbid  products  under  the  mucous  mem- 
brane, or  under  the  epidermis,  by  puncture  or  scarification,  we 
should  be  satisfied  here  with  proof  of  the  first  proposition. 

III.     Transmis.sion  by  Inoculation. 

m  this  chapter  must  be  comprised  all  cases  in  which  the 
virus  has  been  introduced  into  the  sub-cutaneous  connective  tis- 
ue,  or  deposited  on  the  surface  with  a  solution  of  continuity  of 
skin  or  mucous  membrane.  These  facts  should  be  classed  in 
two  categories.  The  first  comprises  those  which  have  been 
obtained  by  experimentation ;  the  second,  those  which  were 
produced  accidentally. 

First.     Cases   From  Experiment. — Since  Bretonneau,  persons 


DEVELOPMENT    OF    EPIDIMICS.  331 

have  been  greatly  inclined  to  believe  in  the  possibility  of  inoc- 
ulation of  diphtheria. 

"  I  have  made,  "  says  the  physician  of  Tours,  "  some  fruitless 
attempts  to  communicate  diphtheria  to  animals.  "  Reynal  has 
inoculated  by  puncture  and  by  rubbing,  chickens,  with  bloody 
debris  of  false  membranes  taken  from  chickens  attacked  with 
croup.  The  result  has  always  been  negative.  These  re- 
searches have  reference  to  but  one  single  species  of  animals, 
and  nothing  is  said  about  the  disease  which  produces  false 
membranes  in  chickens  being  submitted  to  the  same  conditions 
of  propagation  as  diphtheria.  Rarley  made  four  inoculations 
which  produced  no  results.  However,  the  animals  were  sac- 
rificed, one  twenty-four  hours,  the  other  four  days  after  the  in- 
oculation. A  longer  delay  would  have  been  necessary  in  order 
to  confirm  the  negative  result  of  the  experiment. 

Ilueter  and  Tommasi  tried  subcutaneous  inoculation  in  five 
rabbits  with  false  membrane  from  the  trachea  expelled  by  ex- 
pectoration,and  with  pharyngeal  concretions  detached  by  means 
of  forceps.  These  fragments  of  false  membrane  were  carried 
into  the  muscles  of  the  back.  The  animals  all  died  from 
twenty-four  to  forty  hours  after  the  inoculation,  with  symptoms 
"very  different  from  putrid  septicemia."  The  authors  noticed 
a  haemorrhagic  infiltration  of  the  wound  and  of  the  surrounding 
muscular  tissue.  Other  animals  inoculated  with  a  bit  of  the 
muscles  thus  altered,  succumbed  at  the  end  of  thirty  hours. 
The  autopsy  revealed  the  same  lesions.  There  was  nothing  to 
indicate  that  diphtheria  had  been  communicated  as  a  conse- 
quence of  these  experiments.  The  principal  argument  of  the 
authors  is  that  they  found  in  the  blood  of  the  animals  after  kill- 
ing them,  small  organisms  which  they  designated  as  character- 
istic of  diphtheria,  organisms  which  were  seen  in  the  false  mem- 
branes inoculated,  and  which  did  not  exist  in  the  blood  previous 
to  the  experiment.  It  is  demonstrated  that  these  organisms  are 
to  be  seen  in  many  infectious  diseases,  in  grave  fevers,  and  that 
they  have  nothing  peculiar  to  diphtheria.  The  authors  have, 
therefore,  produced  symptoms  of  experimental  septicaemia. 
There  was  nothing  resembling   diphtheria  in  the  lesions  which 


332  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

followed  their  inoculations.  Eberth,  of  Zurich,  engrafted  (im- 
plantation) false  membranes  upon  the  cornea  of  animals.  He 
saw  develop,  after  twenty-four  hours,  a  gray  opacity,  and  an 
ulceration  which  showed  no  tendency  to  cicatrize,  while  a  sim- 
ple traumatic  lesion  healed  rapidly.  These  experiments  again 
prove  nothing  on  the  inoculability  of  diphtheria.  Ulcerations 
of  an  unhealthy  kind,  like  all  those  which  have  their  origin  from 
septic  products  were  obtained  on  the  cornea.  That  these  were 
diphtheritic  lesions  in  the  German  sense  of  the  word,  I  do  not 
deny,  but  that  they  represent  manifestations  of  the  specific 
disease  diphtheria  would  be  difficult  to  sustain.  Prof  Felix, 
of  Bucharest,  tried  to  inoculate  diphtheritic  false  membranes 
upon  animals,  and  upon  varicose  ulcers  in  man.  Although  the 
trials  were  made  nearly  always  with  fresh  products,  the  results 
were  negative.  Homolle,  seeking  to  verify  (control)  the 
notions  of  Letzerich,  cultivated  by  the  method  of  this  author, 
the  spores  found  on  the  surface  of  diphtheritic  false  membranes. 
The  products  were  inoculated  into  rabbits,  as  well  as  the  spores 
collected  immediately  upon  the  false  membranes.  Septicaemic 
symptoms  without  special  characteristics  were  the  result.  In 
the  blood  of  these  animals  were  found  bright  moving  corpuscles 
attributed  by  some  observers  to  diphtheria,  but  which  are  now 
recognized  as  belonging  to  septicaemia  and  to  several  infectious 
conditions. 

Other  experiments  were  tried  by  the  same  author,  and  with 
the  same  result  by  inoculating  rabbits  with  blood  collected  dur- 
tracheotomy  from  patients  affected  with  croup.  It  was  the 
same  when  pieces  of  false  membrane  were  placed  in  contact  with 
denuded  epidermis.  In  one  of  the  animals  experimented  on 
the  injection  of  blood  was  combined  with  the  application  of  frag- 
ments of  false  membranes  to  the  conjunctiva  previously  cau- 
terized. Duchamp  also  undertook  several  experiments  of  the 
same  kind  and  injected  under  the  skin  into  the  jugular  vein  of 
rabbits,  and  under  the  epidermis  of  a  horse  fragments  of  false 
membranes:  the  results  were  nil. 

Experiments  Made  on  Man. — These  are  negative,  but  of 
little  value  because  of  their  rarity.  Trousseau  first  had  the 
courage  to  inoculate    himself   with    diphtheria    products.      He 


DEVELOPMENT    OF    EPIDEMICS.  333 

dipped  a  lancet  into  a  false  membrane,  which  he  had  just  re- 
moved from  a  diphtheritic  patch,  and  made  with  it  a  puncture 
in  the  left  arm,  and  then  five  or  six  in  the  tonsils  and  in  the 
velum.  He  saw  a  vesicle  quite  similar  to  that  of  vaccine  de- 
velop on  the  arm  at  the  place  of  puncture;  nothing  appeared 
upon  the  mucous  membrane.  Peter  made  upon  his  lower  lip  three 
punctures  with  a  lancet  charged  with  semi-fluid  matter  recog- 
nized by  the  microscope  as  diphtheritic.  One  only  of  these 
punctures  showed,  for  some  hours  after  the  inoculation,  an  ec- 
chymotic  prominence.  No  disturbance  in  the  health  super- 
vened. Duchamp  repeated  the  experiments  of  Peter  with  the 
same  results. 

Like  the  trials  made  on  animals,  these  having  man  for  the 
subject  were  negative.  Before  pronouncing  finally  upon  the 
experimental  inoculability  of  diphtheria,  more  numerous  cases 
would  be  necessary,  especially  in  man.  It  would  be  interest- 
ing to  know  what  would  produce  a  false  membrane  when  ap- 
plied to  a  blistered  surface. 

Second.  Accidental  Inoculations. — Persons,  especially  phy- 
sicians, have  been  attacked  with  diphtheritic  angina  after  being 
wounded  with  an  instrument  soiled  with  blood  from  patients 
attacked  with  croup.  Similar  results  have  followed  the  con- 
tact of  wounds  of  the  extremities,  with  pseudo-membranous 
products. 

These  facts  have  received  different  interpretations.  Several 
authors  have  questioned  whether  it  is  not  necessary  to  regard 
them  as  examples  of  inoculation  of  diphtheria  by  blood  or  by 
false  membranes ;  while  others  have  contended  that  these 
diphtheritic  manifestations  had  no  relation  of  causality  with 
the  punctures,  and  that  they  were  solely  the  result  of  infection 
from  a  diphtheritic  focus  in  which  the  persons  lived. 

May  any  formal  conclusions  be  deduced  from  these  facts  ? 
Let  us  examine  first  those  in  which  the  blood  was  the  agent 
of  inoculation,  then  we  will  pass  in  review  those  which  refer  to 
contact  of  diphtheritic  products  with  wounds. 

A.  Inoculation  by  the  blood. — Bergeron  communicated  to 
the  Societe  des  Hopitaux  the  history  of  two  patients,  both 
physicians,  who  found  themselves  in  these  conditions : 


334  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

The  first,  Dr.  Loreau,  punctured  his  finger  with  a  bistoury 
which  some  one  had  just  used  in  performing  tracheotomy  in  a 
case  of  croup.  An  angioleucitis  arose  along  the  arm  simulta- 
neously with  a  small  abscess  at  the  site  of  the  puncture.  Fif- 
teen days  later,  when  his  finger  was  not  yet  entirely  well,  he 
exposed  himself  to  intense  cold  ;  in  the  evening  he  experienced 
chills,  and  in  the  night  pain  in  the  throat.  The  next  day  a 
false  membrane  appeared  on  one  of  the  tonsils  and  reached  the 
other  the  next  day.  Recovery,  however,  took  place,  but  was 
followed  by  general  paralysis.  The  wife  of  our  colleague  took 
the  disease  from  her  husband  ;  she  also  recovered,  but  like  him 
did  not  escape  consecutive  general  paralysis.  The  paralysis 
in  one  of  these  cases  continued  four  months. 

The  second,  Mr.  Baudrey,  a  student  of  medicine,  after  suf- 
fering for  two  days  with  cold  in  the  head,  the  result  of  a  sud- 
den suppression  of  a  free  perspiration,  was  making  z.  post  mor- 
tem, examination  of  a  child  dead  of  croup,  and  he  slightly 
punctured  his  left  thumb.  Free  washing  with  water,  sucking 
it  for  some  time,  and  pressure  made  the  wound  bleed  freely. 
Nevertheless,  in  the  evening,  symptoms  of  an  angioleucitis 
which  extended  to  the  entire  left  arm,  manifested  themselves. 
Five  days  after  the  chill,  two  days  after  the  autopsy,  a  sore 
throat  supervened,  accompanied  by  sub-maxillary  swelling. 
The  next  day  the  angina  increased,  and  three  days  later  diph- 
theritic false  membranes,  of  limited  extent,  however,  were  dis- 
covered on  the  tonsils.       The  disease  terminated    in    recovery. 

A  surgeon  of  Elberfeld,  Prof.  O.  Weber,  while  performing 
tracheotomy  on  a  child  affected  with  croup,  wounded  his 
thumb.  A  whitlow,  an  angioleucitis  of  the  forearm  and  arm- 
an  axillary  adenitis,  and  later  a  diphtheritic  angina  with 
croupal  cough  were  the  result. 

Thomas  Hillier  speaks  of  a  surgeon  who,  while  performing 
tracheotomy  on  a  child  affected  with  croup,  punctured  his 
thumb.  The  next  day  he  felt  a  sharp  pain  at  the  site  of  injury. 
The  second  day  there  appeared  at  the  spot  a  pustule,  beneath 
which  an  unhealthy  ulcer  formed.  At  the  same  time  general 
symptoms  appeared   which   compelled   the  physician    to  take 


DEVELOPMENT    OF    EPIDEMICS.  335 

his  bed.  Soon  after  the  existence  of  diphtheria  of  the  throat 
was  recognized  which  recovered.  At  the  end  of  four 
weeks  disturbances  of  motion  in  the  limbs  similar  to  ataxia 
occurred.  The  ulceration  of  the  thumb  required  four  weeks 
to  cicatrize.  These  two  latter  cases,  however  incomplete  they 
may  be  in  respect  of  details  and  dates,  belong  to  the  same 
category  as  those  of  Bergeron's.  They  are  all  cases  of  phy- 
sicians attacked  with  diphtheria  after  being  inoculated  with 
blood  from  subjects  suffering  from  the  disease.  Must  a  rela- 
tion of  cause  and  effect  be  established  between  the  two  inci- 
dents, or  a  simple  relation  of  coincidence  ?  So  far  as  the  first 
two  cases  are  concerned,  the  eminent  clinician  who  observed 
them,  hesitates  to  express  himself.  While  the  second  hy- 
pothesis appeared  to  him  the  most  acceptable,  the  first  did  not 
seem  inadmissable.  In  fact,  one  finds  himself  between  two 
hypotheses.  Strict  argument  does  not  permit  of  one  being 
preferred  to  the  other.  Roger  has  taken  strong  grounds 
against  that  of  inoculation.  In  fact,  one  may  oppose  numer- 
ous objections  to  this  view  of  the  case. 

The  duration  of  incubation  which  in  the  first  case  was  said  to 
be  fifteen  days,  appears  to  Roger  too  long,  who  admits  that  this 
period,  with  exceptions,  requires  not  more  than  from  two  to 
seven  days.  One  may,  it  is  true,  accord  to  this  case  the  benefit 
of  the  exception  ;  but  the  second  may  dispense  with  this  favor 
since  the  sore  throat  appeared  two  days  after  the  puncture, 
and  the  false  membranes  five  days  after  the  same  date.  The 
absence  of  diphtheritic  manifestations  at  the  point  where  the 
virus  is  said  to  have  penetrated,  has  also  been  offered  against 
the  notion  of  inoculation  in  these  cases.  Variola,  vaccinia, 
and  syphilis,  producing,  indeed,  at  the  point  of  inoculation  a 
a  characteristic  lesion,  one  might  require  as  proof  of  the  inocu- 
lation of  diphtheria,  the  formation  of  a  false  membrane  at  the 
point  injured.  Bergeron  responded  that  this  was  not  a  neces- 
sary condition,  and  cited  the  example  of  glanders,  hydrophobia 
and  certain  cases  of  variola.  Yet,  it  must  be  admitted  that 
one  case  should  receive  great  importance  in  satisfying  that 
point.     The  surgeon  cited  by  Thomas   Hillier  presented,  as  a 


336  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

matter  of  fact,  at  the  injured  place  an  ulceration  of  unhealthy 
character  which  required  four  weeks  to  cicatrize  ;  unfortunately 
the  author  did  not  say  whether  it  was  covered  with  diphtheria. 
But  the  chief  objection  is  the  following:  The  persons  who  are 
supposed  to  have  contracted  diphtheria  by  inoculation,  lived 
in  the  locality  (foyer)  of  an  epidemic,  and  were  found  in  fre- 
quent contact  with  patients  affected  with  diphtheria;  they 
were,  therefore,  placed  under  favorable  conditions  to  be  con- 
taminated at  a  distance,  by  the  surrounding  air  and  by  inhala- 
tion. Moreover,  if  we  admit  that  diphtheria  might  have  the 
power  of  transmitting  itself  by  the  inoculation  of  the  blood 
we  would  accord  to  this  disease  a  power  of  inoculability  still 
greater  than  to  others,  such  as  variola  and  syphilis  which  are 
so  capable  of  inoculating.  Variola,  in  fact,  does  not  transmit 
itself  by  this  means,  as  to  syphilis,  adhiic  siib  jiidice  lis  est. 

["That  the  blood  of  a  syphilitic  person  may  prove  the  source 
of  contagion,  has  been  demonstrated  by  both  experiment  and 
clinical  experience,  as  well  as  by  observation  of  the  fact  that 
syphilis  may  be  transmitted  by  vaccination  when  blood  is 
mixed  with  the  lymph  obtained  from  a  syphilitic  child,  while 
vaccine  matter  does  not  appear  to  be  capable  of  conveying 
syphilitic  infection,  if  care  be  taken  to  exclude  the  admixture 
of  blood.  It  has  been  recently  suggested  that  syphilis  may  be 
conveyed  in  vaccination  by  the  admixture  with  vaccine  lymph 
of  epidermic  scales,  or  of  pus,  as  well  as  of  blood." — Ashhitrst.'] 

One  may  still  reply  that  many  operators  wound  themselves 
in  performing  tracheotomy  without  experiencing  any  conse- 
quences. This  argument  has  but  little  value  and  does  not 
prove  the  non-inoculability  of  diphtheria  but  only  the  negative 
result,  in  certain  cases  of  contact  of  the  false  membrane,  not 
affirming  the  transmissibility  of  this  disease  by  direct  contact. 
It  is,  therefore,  very  difficult  to  decide  upon  the  value  of  the 
cases  just  cited.  In  order  that  inoculations  of  this  kind  may 
be  of  value  they  must  be  produced  in  a  medium  exempt  from 
diphtheria.  The  most  that  can  be  said  is  that  it  is  impossible 
to  prove  beyond  question  the  inoculability  of  diphtheria  by 
means  of  the  blood.     IMoreover,   by    examining   closely  these 


DEVELOPMENT    OF    EPIDEMICS.  337 

cases,  we  observe  at  least  in  three  of  them  that  the  symptoms 
following  the  puncture  are  of  two  kinds :  First,  phenom- 
ena of  septicaemia,  characterized  by  angioleucitis,  adenitis,  and 
frequently  by  general  symptoms  ;  then  diphtheritic  manifesta- 
tions. So  that  if  the  blood  of  diphtheritic  subjects  does  not 
transmit  diphtheria,  it  introduces  into  the  organism  septic 
products  which  may  develop  therein  dangerous  symptoms. 
As  corroboratory  evidence,  I  can  add  to  the  preceding  cases 
the  one  of  my  friend.  Dr.  Pouquet,  who,  having  slightly  punc- 
tured his  finger  in  performing  a  tracheotomy,  was  attacked 
with  severe  erysipelas  and  dangerous  septicaemic  symptoms 
which  for  a  long  time  endangered  his  life.  No  diphtheritic 
manifestations  were  produced,  If  the  appearance  of  diph- 
theria in  the  first  patient  was  not  the  direct  result  of  inocula- 
tion it  is  very  possible  that  the  profound  disturbances  pro- 
voked by  the  septic  poisoning  may  have  made  the  organism  a 
suitable  soil  for  the  development  of  the  morbid  germs  with 
which  it  was  found  in  contact  and  favored,  consequently,  the 
appearance  of  diphtheria. 

B.  Inoculation  ivith  False  Membrane. — Diphtheria  has  been 
seen  several  times  to  supervene  in  persons  having  at  the  time 
wounds  which  had  been  placed  in  contact  with  diphtheritic 
products.  It  has  been  asked  whether  there  had  been  inocu- 
lation in  these  cases.  The  only  cases  coming  under  my  obser- 
vation were  four. 

The //-J/  was  reported  by  Guersant.  A  boy  had  sores  on  his  feet ;  walked  barefoot 
on  the  floor  where  another  having  diphtheria  had  spit  The  first  got  eschars  between 
his  toes. 

The  second  was  witnessed  by  Trousseau.  It  is  more  convincing.  During  the  ep- 
idemic of  Cologne  a  mother  who  was  suckling  her  child  affected  with  diphtheritic 
angina,  had  upon  both  breasts  patches  of  false  membrane. 

The  third \%  due  to  E.  Bonnet  of  Poitiers:  "A  mother,  40 years  of  age,  in  the  prime 
of  life  and  of  good  constitution,  received  an  injury  on  the  left  index  finger  a  few  days 
previously.  The  wound  was  in  a  fair  way  to  recover.  Her  daughter,  14  years  of 
age,  was  attacked  with  the  disease  (diphtheritic  angina),  and  the  mother  wishing  to 
cauterize  the  false  membrane  in  the  throat  of  this  child  was  bitten  precisely  on  the 
wound  of  the  finger.  The  next  day  the  wound  became  painful,  assumed  a  pale  aspect 
and  7i.faLe  membrane  developed  there ;  the  day  after  the  arm  was  swollen,  distended, 
livid  and  purplish.      A  blister  as  a  preventive  (de  precaution)  which  this  woman  had 


338  DIPHTHERIA,  CROUP  AND  TRACHEOTOMY. 

on  her  arm  became  gangrenous.  The  enormous  tumefaction  of  the  arm  extended  b» 
the  chest,  and,  without  having  called  in  the  aid  of  any  intelligent  persons,  she  died 
on  the  sixth  day,  the  next  day  after  the  death  of  her  daughter." 

Thu  fourth  is  reported  by  Paterson  of  Aberdeen  A  farmer,  43  years  of  age,  ia 
three  weeks  lost  three  children  from  croup.  Without  giving  any  attention  to  a  re- 
cent wound  which  he  had  on  the  right  index  finger,  one  day  he  introduced  this  finger 
into  the  throat  of  the  last  of  his  children  while  attending  to  it  The  wound,  until  then 
perfectly  simple  and  painless,  inflamed,  became  painful  and  covered  with  a  false 
membrane  which  persisted  for  eight  days.  The  throat  remained  intact,  but  at  the 
end  of  a  month  a  paralysis  supervened  which  implicated  all  four  of  the  extremities 
while  exempting  the  throat     Complete  recovery  required  four  months. 

These  cases,  like  he  former  ones,  are  open  to  criticism, 
the  persons  who  furnished  them  were  living,  for  a  certain  time, 
in  an  epidemic  center.  The  germs  of  the  disease,  therefore, 
might  have  penetrated  the  organism  by  another  channel. 
There  is  in  this  suppposition  nothing  unreasonable.  Yet  one 
may  legitimately  find  for  the  diphtheritic  intoxication  another 
source.  I  abandon  at  once  the  first  case,  that  of  Guersant. 
The  three  others,  on  the  other  hand,  present  considerable  im- 
portance. It  has  been  objected  to  the  one  from  Trousseau 
that  the  mother  might  have  had  fissures  of  the  nipples  and 
that  those  little  sores  could  have  become  covered  with  diph- 
theria without  it  being  necessary  to  appeal  to  their  contact 
with  the  morbid  matter.  That  is  to  answer  by  a  hypothesis, 
to  condemn  a  fact  as  hypothetical.  On  the  contrary,  the  de- 
velopment of  false  membranes  at  the  contaminated  spot  is  of 
much  importance,  in  favor  of  the  entrance  of  the  virus  by  this 
channel.  In  the  last  two,  the  wounds  of  the  fingers,  the  one 
painless  and  the  other  nearly  cicatrized,  both  became  painful 
the  next  day  after  their  introduction  into  the  mouth  of  the  pa- 
tients, and  then  became  covered  with  false  membranes.  In  one 
of  the  patients,  a  pre-existing  blister  became  coated  with  diph- 
theritic concretions,  after  the  ivound  of  the  finger.  The  last  es- 
caped, it  is  true,  from  the  other  local  manifestations  of  diph- 
theria, but  general  paralysis  confirmed  the  nature  of  the  disease. 
The  probabilities  are  all  in  favor  of  the  view  that  the  two 
wounds  served  as  the  channel  of  entrance  to  the  morbific 
germs.  If  these  latter  followed  this  channel,  everything  tends 
to  the  belief  that  they  were   introduced  at  the  moment   when 


DEVELOPMENT    OF    EPIDEMICS.  339 

the  denuded  integument  was  placed  freely  in  contact  with 
them  in  the  mouth  of  the  patients.  One  might  object  that 
they  found  access  in  one  of  the  two  cases  by  the  blistered  sur- 
face. But  this  blister  became  diseased  after  the  wound 
of  the  finger.  The  objection,  therefore,  is  valueless;  con- 
sequently these  two  cases  have  all  the  characters  of  those  in 
which  the  inoculation  is  beyond  question,  viz.,  the  specific 
morbid  product  is  produced  at  the  place  injured,  and  general 
impregnation  of  the  economy  is  manifested  afterwards.  There 
is  nothing  wanting  in  the  usual  chain  of  morbid  phenomena. 
We  are  then,  it- seems  to  me,  in  a  position  to  admit  that  there 
was  true  inoculation  of  diphtheritic  products.  I  do  not  wish 
to  state  that  the  saliva  of  itself  may  be  charged  with  morbid 
principles  which  it  draws  from  the  economy  by  secretion,  as  oc- 
curs in  rabies.  The  saliva  of  a  patient  affected  with  cutaneous 
diphtheria  of  whom  the  throat  remains  sound,  probably  has  no 
power  of  inoculation.  In  three  of  the  above  cases,  the  injuries 
of  the  nipples  and  of  the  fingers,  if  they  were  not  in  direct 
contact  with  the  false  membranes,  were  impregnated  with  the 
saliva  which  remained  in  long  contact  with  the  false  mem- 
branes and  served  as  a  vehicle  to  the  particles  of  false  mem- 
branes as  well  as  to  the  fluids  oozing  from  the  diseased 
surfaces. 

[The  following  are  the  conclusions  of  Drs.  Curtis,  and  Satter- 
thwaite,  of  New  York,  drawn  from  their  extensive  and  carefully 
conducted  experiments  on  animals  : 

"The  results  of  our  investigations  may  be  summed  up  as 
follows  : 

I.  "  Inoculation  of  diphtheritic  membrane  into  the  muscular 
tissue  of  the  rabbit  produces  severe  local  lesions,  and  even 
constitutional  disturbance  and  death.  But  these  effects  differ 
so  in  their  pathology  and  clinical  history  from  diphtheria  in  the 
human  subject  that  there  is  no  warrant  for  defining  them  as 
diphtheria,  or  for  applying  conclusions  drawn  from  observation 
of  this  inoculation-disease  in  the  rabbit  to  the  case  of  diph- 
theria in  man. 

II.  "  Effects  exactly  similar  to  the    foregoing  and  of  equal 


340  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

severity  can,  moreover,  be  produced  by  inoculation  of  a  ma- 
terial not  only  non-diphtheritic,  but  non-infectious  to  the  human 
subject  under  conditions  where  diphtheritic  membrane  is  in- 
fectious, t.  ^.,when  brought  into  contact  with  the  mucous  mem- 
brane of  the  mouth  and  throat.  The  material  referred  to  is 
the  pulpy  scraping  of  the  upper  surface  of  the  human  tongue. 

III.  "  Effects  generally  similar  to  the  foregoing,  though  not 
of  equal  intensity,  can  furthermore  be  produced  by  inoculation 
of  a  putrescent  matter  which  is  not  even  of  immediate  animal 
origin,  namely  Cohn's  fluid,  allowed  to  spontaneously  decom- 
pose. Cohn's  fluid  is  simply  an  aqueous  solution  of  ammonic 
tartrate,  potassic  and  calcic  phosphates  and  magnesic  sul- 
phate. 

IV.  "  The  foregoing  inoculation  effects  are  not  due  to  sim- 
ple mechanical  irritation,  for  inoculations  of  sand  produce  no 
effect  whatever. 

V.  "Thorough  filtration  of  a  proven  virulent  aqueous  infusion 
of  diphtheritic  membrane  or  of  putrid  Cohn's  fluid  removes  the 
infectious  property  of  the  same.  Hence  in  such  diphtheritic  in- 
fusion the  poisonous  quality,  probably  inheres  in  some  pai'tic- 
ulate  thing,  from  which  it  is  not  separable  by  the  action  of  cold 
water. 

VI.  "Thorough  trituration  of  proven  virulent  diphtheritic 
membrane  and  tongue-scrapings  with  a  high  percentage  of  sal- 
icylic acid  fails  not  only  to  remove,  but  even  markedly  to  mod- 
ify the  intensity  of  the  infectious  quality  of  those  substances. 
Hence,  since  sahcylic  acid  in  even  a  minute  percentage  is 
capable  of  permanently  suspending  the  vital  activity  of  bac- 
teria, the  inference  is  that  the  infectious  qualities  of  diphthe- 
ritic membrane  upon  the  system  of  the  rabbit  is  not  correlated 
to  the  vital  activity  of  the  bacteria  present  in  such   membrane. 

VII.  "  If,  as  is  not  improbable,  the  noxious  principle  in  the 
diphtheritic  membrane  which  produces  in  rabbits  the  effects 
described,  be  the  same  with  or  even  analogous  to  the  principle 
which  produces  diphtheria  in  man  by  direct  infection,  then  the 
conclusion  of  VI.  will  apply  to  the  infectious  quality  of  such 
membrane  in  its  relation  to  the   reproduction  of  diphtheria  in 


DEVELOPMENT    OF    EPIDEMICS.  34 ^ 

the  human  subject.  If  this  be  the  case  it  follows  as  an  impor- 
tant practical  corollary  that  there  is  no  theoretical  gromid  for 
assuming  that  preventing  the  bacteria  of  a  diphtheritic  patch 
from  making  their  way  through  the  underlying  mucous  mem- 
brane will,  per  se,  prevent  general  diphtheritic  infection  of  the 
system. 

VIII.  "There  is  no  relation  between  inoculable  virulence 
of  a  diphtheritic  membrane  and  the  period,  within  three  days, 
that  has  elapsed  between  the  detachment  of  the  membrane 
and  the  inoculation  with  the  same,  nor  between  inoculable 
virulence  and  gross  amount  of  bacteria  present  on  the  mem- 
brane. 

IX.  "There  is  a  rough  relation  between  inoculable  virulence 
of  a  diphtheritic  membrane  and  the  severity  of  the  original 
case  of  diphtheria,  so  far  as  this  can  be  estimated  by  the  ter- 
mination of  the  case  in  death  or  recovery. 

"But  it  must  be  distinctly  understood  that  these  nine  propo- 
sitions are  not  put  forth  as  proven,  but  merely  as  the  results  of 
our  experiments  and  observations,  so  far  as  the  latter  go, 
stated  in  abstract  form.  Before  the  propositions  can  be  con- 
sidered proved  as  truths,  a  large  number  of  corroborative  ex- 
periments will  have  to  be  made."] 

[Drs.  Wood  and  Formad,  of  Philadelphia,  close  their  interest 
ing  report  on   the  same  subject  with  the  following  comments  : 

"  In  looking  over  the  last  table  it  will  be  seen  that  in  two  of 
the  ten  experiments  pseudo-membranous  trachitis  was  caused 
by  the  introduction  of  organic  matter  into  the  trachea.  In 
both  of  the  cases  in  which  false  membrane  was  produced,  the 
injected  material  was  pus;  and  it  will  be  noticed  that  only  four 
such  experiments  were  made,  so  that  the  proportion  of  suc- 
cessful results  is  very  large  ;  much  larger,  indeed,  than  with 
true  diphtheritic  exudation  in  our  experiments. 

"  Trendelenburg  found  that  not  only  ammonia,  but  also 
various  other  chemical  irritants  are  capable  of  causing  the 
formation  of  false  membrane  in  the  trachea ;  many  years  since 
it  was  proven  that  tincture  of  cantharides  will  do  the  same 
thing.  It  would  seem,therefore,that  in  the  trachea,the  formation 


342  DIPHTHERIA,  croup  and  tracheotomy. 

of  a  pseudo-membrane  is  not  the  result  of  any  peculiar  or 
specific  process,  but  simply  of  an  intense  inflammation  which 
may  be  produced  by  an  irritant  of  sufficient  power.  This  fact, 
certainly,  is  very  suggestive  in  regard  to  the  pathology  of 
diphtheria,  and  whilst  we  are  not  prepared  to  commit  ourselves 
to  any  theory,  it  does  seem  proper  to  call  attention  to  cer- 
tain facts  as  indicating  a  very  simple  explanation  of  the  pecu- 
liarities of  the  disease. 

"It  is  certain  that  as  in  the  lower  animals,  so  also  in  man,  will 
chemical  irritants  produce  a  pseudo-membranous  trachitis  ;  we 
are  also  well  assured  that  there  is  no  anatomical  difference 
which  can  be  detected  with  the  microscope  between  the  lesions 
of  true  croup  and  diphtheritic  angina.  A  difference  has  been 
believed  by  some  pathologists  to  exist  between  the  two  dis- 
eases, in  that  in  croup  the  membrane  separates  easily,  in 
diphtheria  with  great  difficulty  from  the  mucous  membrane. 
This  seems  to  arise  from  a  misunderstanding. 

"  The  mucous  membrane  of  the  fauces  and  mouth  has  a 
squamous  not  easily  detached  epithelium,  and  consequently 
membrane  connected  with  or  springing  from  such  surface  is 
firmly  adherent.  The  epithelium  of  the  trachea  is  columnar, 
ciliated,  and  detaches  with  the  utmost  facility,  even  in  normal 
conditions  of  the  organ  ;  hence,  membrane  attached  to  it  sepa- 
rates readily.  The  membrane  of  diphtheritic  trachitis  is  always 
readily  detached  in  the  line  of  the  epithelium.  Our  prepara- 
tions also  show  that  the  exudation  of  the  croupous  inflamma- 
tion excited  artificially  in  the  trachea  is  not  merely  superficial, 
but  also  extends  below  the  basement  membrane.  Some  of  the 
best  clinical  authorities  of  the  day  teach  that  there  is  no  essen- 
tial clinical  difference  between  true  croup  and  diphtheria,  cases 
commencing  apparently  as  local  sthenic  inflammation  and  end- 
ing as  the  typical  adynamic  systemic  poisoning.  Every  prac- 
titioner must  have  seen  cases  of  angina  in  which  he  was  in 
doubt  whether  to  call  the  affection  diphtheria  or  not;  the  very 
frequent  diagnosis  of  "  diphtheritic  sore  throat "  is  a  strong 
evidence  of  this.  There  have  been  cases  in  which  diphtheritic 
matters  absorbed   by  a  wound  have  produced  symptoms  very 


DEVELOPMENT    OF    EPIDEMICS.  343 

closely  resembling  those  of  ordinary  septic  blood  poisoning 
from  post-mortem  wounds,  etc. ;  there  have  been  cases  of  the 
formation  of  false  membrane  about  wounds,  etc.,  without  any 
known  exposure  to  a  specific  diphtheritic  poisoning,  indicating 
that  the  systemic  tendency  to  this  peculiar  form  of  exudation  is 
capable  of  being  engendered  by  other  than  the  specific  poison 
of  diphtheria;  finally  diphtheria  seems  sometimes  to  be  pro- 
duced by  exposure  to  cold. 

"  A  general  view  of  these  facts  seems  to  indicate  that  the 
contagious  material  of  diphtheria  is  really  of  the  nature  of  a 
septic  poison,  which  is  also  locally  very  irritant  to  the  mucous 
membrane  ;  so  that  when  brought  in  contact  with  the  mucous 
membrane  of  the  mouth  and  nose  it  produces  an  intense  in- 
flammation without  absorption  by  local  action.  Whilst  ab- 
sorption is  not  necessary  for  the  production  of  angina,  it  is  very 
possible  that  the  poison  may  act  locally  after  absorption  by  be- 
ing carried  in  the  blood  to  the  mucous  membrane.  Further, 
under  this  theory,  it  is  possible  that  the  poison  of  diphtheria  may 
cause  an  angina  which  shall  remain  a  purely  local  disorder,  no 
absorption  occurring,  or  a  simply  local  trachitis  produced  by 
exposure  to  cold,  or  some  other  non-specific  cause  may  prc^- 
duce  the  septic  material  when  absorption  shall  cause  blood 
poisoning,  the  case  ending  as  one  of  adynamic  diphtheria. 

"Some  such  an  explanation  as  those  here  offered  seems  to 
reconcile  antagonistic  opinions  concerning  the  value  of  local 
treatment  in  diphtheria;  because  it  is  plain  that  the  value  ot 
such  treatment  must  largely  depend  upon  whether  the  angina 
has  or  has  not  been  preceded  by  absorption. 

"  There  is  one  more  important  clinical  feature  of  the  disorder, 
which  under  other  views  of  the  disease  seems  inexplicable,  but 
which  with  the  present  theory  is  easily  explained.  Diphtheria 
differs  from  the  exanthemata  by  the  fact  that  one  attack  in  no 
way  protects  against  the  second.  It  will  be  seen  that  the 
theories  here  put  forward  remove  the  affection  entirely  from 
any  relation  with  exanthemata;  placing  it  rather  with  septic  dis- 
eases, which,  as  is  well  known,  may  recur  indefinitely. 

"  We  want,  however,  distinctly  to  state,  that  we   do  not  con- 


344  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

sider  these  ideas  to  be  more  than  suggestions,  and  it  is  useless 
to  speculate  except  as  a  guide  to  further  experimental  research. 
It  does  seem  to  us  that  there  are  now  two  pathways  clearly- 
open,  which  if  carefully  followed,  must  lead  to  important  posi- 
tive or  negative  results.  The  first  of  these  consists  in  the  mak- 
ing of  careful  culture  experiments  to  determine  whether  there  is 
or  not  any  difference  between  the  bacteria  of  ammonia  and  diph- 
theritic false  membranes;  the  second,  the  study  of  the  induction 
of  epidemics  of  pseudo-membranous  angina  and  trachitis  in  the 
lower  animals,  and  the  relation  to  these  of  the  rapid  cases  «f 
death  produced  in  the  lower  animals  by  diphtheritic  inoculation. 
"  There  is  still  another  somewhat  different  view  which  seems 
also  not  repugnant  to  the  known  facts  of  the  case.  There  may 
be  bacteria,  which,  although  they  offer  no  points  of  difference 
detectable  by  our  best  microscopes,  are  really  very  diverse. 
Two  spermatozoa  or  two  ova  in  the  higher  animals,  may  seem 
to  be  exactly  alike,  and  yet  be  potentially  widely  separated. 
Although,  therefore,  the  bacteria  of  an  ammonia  false  mem- 
brane seem  identical  with  those  of  diphtheritic  false  membrane, 
they  are  not  of  necessity  really  so.  Careful  studies  of  the 
blood  of  patients  \Vho  die  of  diphtheria  should  be  made,  but  at 
present  it  seems  altogether  improbable  that  bacteria  have  any 
direct  function  in  diphtheria  i.  e.,  that  they  enter  the  system 
as  bacteria  and  develop  as  such  in  the  system,  and  cause  the 
symptoms.  It  is,  however,  possible  that  they  may  act  upon 
the  exudations  of  the  trachea  as  the  yeast  plant  acts  upon 
sucrar,  and  cause  the  production  of  a  septic  poison  which  differs 
from  that  of  ordinary  putrefaction,  and  bears  such  relations  to 
the  system  as  to,  when  absorbed,  cause  the  systemic  symptoms 
of  diphtheria.  Now,  these  bacteria  may  be  always  in  the  air, 
but  not  in  sufficient  quantities  to  cause  trachitis,  but  enough 
when  lodged  in  the  membrane,  to  set  up  the  peculiar  fermen- 
tation ;  whilst  during  an  epidemic  they  may  be  sufficiently 
numerous  to  incite   an    inflammation  in   a  previously    healthy 

throat."] 

Conclusions. — Experiments  of  great  interest  appear  opposed 
to  the  inoculability  of  diphtheria  from  man  to  animals  by  false 


DEVELOPMENT    OF    EIPDEMICS.  345 

membranes  in  kind  or  by  the  spores  which  have  been  collected 
from  their  surface.  These  experiments  being  yet  few,  and  be- 
ing found  contradicted  by  those  which  prove  the  transmissi- 
bility  of  diphtheria  by  the  contact  of  diphtheritic  products  with 
the  mucous  membranes,  we  may  be  permitted  to  appeal  to 
other  cases.  The  result  obtained  is  very  important  and 
difficult  to  accomplish.  It  is,  aside  from  certain  ex- 
ceptions, more  difficult  to  transmit  a  disease  by  simple  contact 
than  by  occulation,  the  channels  of  absorption  being  more  ac- 
cessible in  the  latter  case.  Many  observers  are  reserved  on  the 
possibility  of  communicating  by  simple  contact,  syphilis  and 
variola  though  so  easily  inoculable.  The  trials  at  inoculation 
from  man  to  man  are  negative,  but  too  few  in  number  to  be  of 
authority,  The  cases  of  accidental  inoculation  with  blood  are 
not  sufficiently  decisive.  This  much  is  certain,  that  they  have 
produced  symptoms  of  septicaemia.  The  cases  of  accidental 
inoculation  with  false  membranes  or  with  liquids  in  contact  with 
them,  appear  established  upon  incontestable  facts.  The  con- 
clusion, therefore,  will  be  with  reserve,  that  diphtheria  is  inocu- 
lable, but  rarely  and  with  difficulty.  This  question,  however, 
presents  an  interest  of  purely  scientific  curiosity  ;  its  practical 
value  appears  nil.  The  utility  of  inoculation  would  exist  only 
in  the  case  in  which  one  might  hope  to  develop  by  this  means 
as  is  done  in  variola,  a  benign  form  of  diphtheria  which  would 
form  a  protection  against  more  serious  attacks  in  the  future. 
But  this  hope  can  in  no  way  be  realized,  since  on  the  one 
hand,  the  benignity  of  inoculated  diphtheria  is  not  demon- 
strated, considering  the  small  number  of  cases,  and,  on  the 
other,  diphtheria  being  a  disease  which  returns,  there  would 
be  no  benefit  in  making  the  adventure. 

IV.  Transmission  by  the  Atmosphere. — If  the  transmissibility 
of  diphtheria  by  direct  contact  and  by  ihcculation  has  been 
contested,  all  accord  to  this  disease  the  faculty  of  propagating 
itself  through  the  surrounding  air.  This  is  the  mode,  par  ex- 
cellence, of  transmission  of  epidemic  and  contagious  diseases. 
It  is  that  which  corresponds  to  what  was  called  propagation 
by   infection,  when   we   could  not  prove  contact  of  the  patient 


346  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

with  a  person  affected  with  any  form  whatever  of  diphtheria. 
The  researches  of  Chalvet,  Rcveil  and  Eidvelt  of  Prague,  have 
discovered  in  the  air  of  hospital  wards,  in  epidemic  seasons,  the 
existence  of  organic  particles,  emanating,  in  all  probability,  from 
the  affected  organisms.  Whether  we  call  them  miasms  or 
spores,  these  infinitely  small  particles,  of  which  the  air  serves 
as  a  vehicle,  have  the  property  of  attaching  themselves  to 
healthy  individuals,  and  on  them  developing  a  disease  similar 
to  that  which  formed  them.  The  respiratory  mucous  mem 
brane  being  of  all  the  other  absorbent  surfaces,  that  which  is 
in  the  most  constant  contact  with  the  air,  is  the  great  channel  by 
which  these  organisms  enter  the  economy*.  In  this  way  transmis- 
sion by  inhalation  is  effected.  But  the  other  mucous  mem- 
branes in  contact  with  the  atmosphere ;  the  conjunctiva,  the 
labial  mucous  membrane,  that  of  the  glans  and  prepuce,  and  of 
the  anus,  while  presenting  to  diphtheria  more  limited  access, 
are  still  under  the  required  conditions  to  absorb  the  morbid 
particles.  These  give  opportunity  for  the  tratismission  by  ab- 
sorption from  the  surface  of  mucous  membranes.  Besides  those 
normal  modes,  there  is  another  purely  accidental.  The  cuta- 
neous surfaces  deprived  of  their  epidermis  possess  also  a  very 
active  absorbent  power.  The  morbific  germs  may  deposit 
themselves  thereon,  and  insinuate  themselves  into  the  economy. 
This  means  of  transmission  differs  from  inoculation,  in  that  the 
denuded  surface  is  not,  as  in  inoculation,  placed  in  direct  con- 
tact with  the  morbid  product  but  by  the  medium  of  surrounding 
air. 

Diphtheria  arises  in  these  different  ways.  It  is  transmitted 
by  inhalation  of  the  surroimdijig  air,  by  absorption  ftom  the  sur- 
face of  mucous  membranes,  and  by  absorption  from  the  surface 
of  wounds. 

Transmission  by  Inhalation. — The  examples  of  this  mode  of 
propagation  have  been  too  often  repeated  to  require  a  demon- 
stration of  its  reality.  The  extension  of  the  disease  to  numer- 
ous individuals  living  in  the  same  place,  inhabiting  the  same 
house,  apartment   or   room  and   sleeping  in  the  same  bed  ;  its 


I 


DEVELOPMENT    OF    EPIDEMICS.  347 

propagation  in  the  hospital  ward  from  the  bed  of  the  importer 
to  the  neighboring  bed,  and  then  from  the  latter  to  the  next 
and  so  on,  as  has  been  observed  many  times,  all  these  cases  are 
eloquent.  In  that  way  are  infected  parents  and  servants, 
friends  who  live  with  the  patients,  and  the  physicians  who  at- 
tend them,  and  among  these  persons  the  most  frequently  at- 
tacked are  those  who  have  been  in  most  devoted  attendance. 
It  was  in  this  way  that  Gillette  contracted  diphtheria  of  which 
he  died.  While  suffering  from  influenza  for  several  days,  he 
brought  from  the  country  some  miles  distant  from  Paris,  in  a 
closed  carriage  a  young  patient  affected  with  croup.  Nine 
days  afterwards  his  fhroat  became  covered  with  false  mem- 
branes, and  diphtheria  rapidly  extended  to  the  entire  respira- 
tory tract.  There  are,  however,  to  this  rule  exceptions,  the 
cause  of  which  resides  in  the  different  aptitudes  of  the  organ- 
isms to  support  the  morbific  germs.  The  agencies  of  conta- 
gion are  carried  away  from  places  where  patients  are  lying  by 
the  surrounding  air,  as  well  as  by  persons  who  have  entered  the 
infected  medium.  In  this  way  the  disease  is  spread  with 
rapidity  through  the  city,  in  the  villages,  barracks  and  every 
place  where  people  are  collected  together.  The  cases  which 
prove  this  mode  of  propagation  are  so  numerous,  so  fully  ad- 
mitted by  all  that  I  deem  it  unnecessary  to  reproduce  them. 
Besides,  I  have  already  quoted  a  sufficiently  large  number  of 
them.  The  extending  power  of  diphtheria  is  considerable.  It 
is  often  with  great  rapidity  that  it  extends  its  ravages  over  an 
entire  country.  Some  times  it  respects,  without  apparent 
cause,  places  comprised  within  the  affected  zone.  The  exten- 
sive contact  of  air  with  the  respiratory  mucous  membrane,  ex- 
plains why  diphtheria  has  its  place  of  election  in  the  pharynx 
and  nasal  fossae.  It  is  in  these  places  that  the  germs  penetrate 
first;  they  there  find  extensive  surfaces  on  which  to  deposit 
themselves.  Those  which  have  not  been  arrested  on  their 
passage,  penetrate  into  the  larynx  and  bronchi ;  here  they  may 
find  a  point  favorable  to  their  development ;  croup  is  then  pri- 
mary, which  is  notably  the  more  rare  form. 

Transmission  by  Absorption  from  the  Surface  of  Mucous  Mem- 


348  DIPHTHERIA,     CROUP    AND    TRACHEOTOMY. 

dranes.— Being  in  contact  with  the  external  air  in  a  much  more 
limited  surface,  the  ocular,  labial,  preputial  and  anal  mucous 
membranes  rarely  aid  in  the  introduction  of  diphtheria.  This 
function,  however,  is  none  the  less  a  fact.  We  see,  in  epi- 
demics, not  only  persons  having,  as  a  single  diphtheritic 
lesion,  a  pseudo-membranous  conjunctivitis,  a  patch  upon  the 
surface  or  on  the  commissure  of  the  lips,  or  indeed  on  the  pre- 
puce or  anus ;  but  it  is  not  rare  that  these  false  membranes 
may  be  the  first  manifestations  of  diphtheria  ;  others  appear 
afterwards  in  the  throat,  nose  and  respiratory  passages,  inde- 
pendently of  propagation  by  contiguity.  These  same  cases  of 
diphtheria,  developed  on  the  external"  mucous  membranes, 
transmit  to  other  patients  diphtheria  mild  or  grave,  localized,  in 
the  same  way  or  otherwise,  or  generalized. 

Transmission  by  Absorptioji  Jrom  the  Surfaces  of  Woiinds. — 
When  a  portion  of  the  cutaneous  surface  is  denuded,  diph- 
thertic  germs  may  there  implant  themselves  and  become  ab- 
sorbed. Blistered  surfaces,  impetiginous  and  eczematous 
ulcerations  and  varicose  ulcers  furnish  favorable  soil.  The  epi- 
demic of  which  Bonnet  speaks  furnishes  interesting  informa- 
tion. Serious  symptoms  produced  at  the  outbreak  had  spread 
terror  through  the  country ;  the  inhabitants  had  sought  a  sure 
preventive  and  had  found  nothing  better  than  a  blister  on  the 
arm.  The  application  of  it  was  adopted  on  a  broad  scale ; 
but  cutaneous  diphtheria  was  not  retarded  in  its  invasion. 
Every  blister  which  Bonnet  saw  was  covered  with  false  mem- 
branes. Trousseau  speaks  also  of  the  bad  effects  of  preventive 
hYis\.tts  {vesicatoifes  de  precatctiofi).  In  addition  to  these  cases 
we  see  in  an  epidemic  locality,  the  least  ulcerations  become  the 
seat  of  diphtheria.  Impetigo  of  the  scalp,  of  the  folds  of  the 
ear,  and  of  the  lips;  eczema  of  the  ear,  scrotum,  or  of  the  cir- 
cumference of  the  anus,  and  simple  excoriation  of  the  folds  of 
the  thighs  in  fat  children  often  open  the  door  to  the  disease- 
Nothing  is  more  common  in  the  wards  of  the  hospital.  Diph- 
theria acquired  in  this  way  is  very  likely  to  spead.  Once  im- 
planted on  a  mucous  surface,  or  on  a  wound,  the  germs  are 


DEVELOPMENT    OF    EPIDEMICS.  349 

absorbed,  provided  they  meet  favorable  conditions,  but, 
though  they  directly  infect  the  economy  and  the  false  mem- 
branes may  be  a  product  of  general  poisoning,  we  see  this 
membrane,  as  in  the  case  of  syphilis,  very  often  spring  up  at 
the  point  through  which  the  morbific  matter  has  entered  into 
the  economy.  This  circumstance  does  not  prevent  the  false 
membranes  from  appearing  simultaneously  or  successively 
upon  other  points  quite  distant.  Infection  once  effected,  the 
vitiated  blood  alters,  by  its  contact,  the  various  organs  and 
excites  the  formation  of  visceral  lesions.  The  intimate  mechan- 
ism of  this  process  is  not  understood. 

§  2.  Conditions  Favoring  the  Vitality  of  the  Germ. — Agencies 
which  have  awakened  and  revived  the  germ,  support  its  vital- 
ity by  prolonging  their  influence.  These  have  been  examined 
in  the  preceding  articles. 

§  3.  Conditions  which  Favor  the  Receptivity  of  the  Organism. 
— We  know  that  diphtheria  transmits  itself  from  individual  to 
individual.  Let  us  examine  the  conditions  which  put  into 
action  this  transmissibility,  in  other  words,  those  which  render 
the  organism  susceptible  of  being  impregnated  by  the  diph- 
theritic germ.  We  will  study  the  influences  of  the  following 
causes :  Damp  cold,  and  sudden  changes  of  temperature,  bad 
hygiene,  depressing  influences,  age,  sex  and  temperament. 

Snddeii  changes  to  damp  cold  temperature  act  upon  the  re- 
ceptivity of  the  individual  as  well  as  upon  the  general  develop- 
ment of  the  epidemic.  They  are  very  active  in  the  production 
of  inflammations  of  the  throat  and  air-passages.  As  in  time 
of  cholera,  simple  indigestion  often  becomes  the  determining 
cause  of  the  attack,  so  a  simple  angina,  a  coryza,  or  a  simple 
laryngitis  may  put  the  naso-pharyngeal  mucous  membrane  in 
the  necessary  condition  for  the  absorption  of  the  diphtheritic 
germs. 

Defective  hygienic  condition  :  viz.,  destitution  and  occupying 
low,  damp,  ill-ventilated  rooms  are  certainly  determining 
causes.  Nearly  every  reporter  of  epidemics  testifies  that  the 
disease  prevails  to  a  greater  extent  among  the  poor.  This  in- 
fluence is  not  exclusive ;   far   from  it,   the   wealthy   class    pays 


350  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

also,  and  even  largely,  its  tribute,  but  it  is  none  the  less  true 
that  the  great  mass  of  patients  affected  with  diphtheria,  are 
seen  at  the  hospital  and  belong  to  the  portion  of  the  poor  pop- 
ulation. To  these  causes  must  be  added  all  those  of  the  same 
kind  which  diminish  the  resisting  powers  of  the  economy,  viz. 
excesses,  emotional  impressions,  fatigue,  and  in  general,  all 
depressing  influences. 

Age  is  one  of  the  most  important  conditions  in  the  devel- 
opment of  diphtheria.  This  disease  is  the  heritage  of  child- 
hood. It  is  met  with,  indeed,  from  the  earliest  infancy,  as 
Bretonneau  has  proved,  to  very  advanced  age,  as  Louis  has 
shewed ;  but  all  authors  are  in  accord  in  assigning  to  it  the 
maximum  of  frequency  in  the  early  years  of  life.  Guersant 
fixes  the  age  from  two  to  seven  years ;  Trousseau  at  that  from 
three  to  six ;  Barthez  and  Rilliet  adopt  the  figures  of  Guer- 
sant. In  the  epidemic  of  Ceyret  all  the  inhabitants  over  24 
years  of  age  escaped.  In  the  epidemic  of  Louhans,  in 
2,500  cases,  1,198  were  children.  Bouiilon-Lagrange  has  pre- 
pared the  following  table  respecting  the  age  of  patients  in  the 
epidemic  which  he  has  described : 


Under  2  years 

14  cases. 

From  18  to  30  years 

-     *s 

From  2  to  6  years 

-    18  cases. 

From  30  to  40  years     - 

-      4 

From  6  to  12  years 

10  cases. 

From  40  to  50  years 

I 

From  12  to  iS  years  - 

9  cases. 

After  50  years      -         -         ■ 

2 

This  places  the  maximum  between  two  and  six  years.  In 
order  to  obtain  the  exact  result  it  would  be  necessary  to  com- 
pare the  figures  furnished  by  several  epidemics  in  which  an 
account  of  all  the  cases  had  been  taken.  Unfortunately  this 
has  not  been  done.  According  to  the  summary  of  the  Epi- 
demiological Society  of  London  the  disease  is  said  to  be  espe- 
cially frequent  during  the  first  ten  years  of  life,  and  particularly 
so  from  the  fifth  to  the  tenth  year.  The  following  table  will  give 
a  result,  as  complete  as  may  be,  respecting  the  earlier  ages. 
It  contains  all  the  cases  of  diphtheria  observed  in  the  service 
of  Barthez  at  the  Saint  Eugenie  during  twenty  years.  They 
are  proportioned  as  follows  : 


DEVE 

-LOPMENT 

OF    EPIDEMICS 

Under  l  year  (ii  mos,) 

4  cases. 

Under  9  years 

Under  i  year    -        -        - 

-  77  cases 

Under  10  years  - 

Under  2  years 

■    314  cases 

Under  11  years 

Under  3  years    -      .        - 

319  cases 

Under  12  years  - 

Under  4  years 

-    292  cases 

Under  13  years 

Under  5  years    -      -        - 

200  cases 

Under  14  years  - 

Under  6  years 

-    103  cases 

Under  15  years 

Under  7  years    -        -        _ 

59  cases 

Under  16  years  - 

Under  8  years 

36  cases 

Under  17  years 

351 


24 

cases 

-  23 

cases 

9 

cases 

12 

cases 

24 

cases 

12  cases 

2 

cases 

-    I 

case 

I 

case 

Total 


1,512  cases 


The  real  maximum  corresponds  to  the  ages  from  two  to 
three  years,  but  up  to  five  years  the  figures  still  remain  quite 
high.  Therefore,  it  is  from  two  to  five  years  of  age  that  diph- 
theria is  most  commonly  observed ;  it  is  emphatically  a  dis- 
ease of  childhood.  The  cause  of  this  preference  is  but  little 
known.  It  has  been  attributed  to  the  greater  plasticity  of  the 
blood  in  the  child ;  nothing  is  farther  from  being  demonstrated. 
It  is  nearer  true  to  say  that  children  have  a  special  affinity  for 
miasmatic  and  contagious  diseases.  They  rarely  escape  mea- 
sles, scarlatina,  small-pox,  or  whooping  congh.  They  should 
be  found  in  similar  conditions  in  respect  to  diphtheria,  a  dis- 
ease of  the  same  order.  Moreover,  their  entire  mucous  mem- 
branes are  particularly  impressible,  and  it  is  with  the  greatest 
facility  that  they  contract  coryza  and  bronchitis.  Perhaps  this 
susceptibility  of  the  mucous  membranes  to  inflame  predisposes 
also  these  membranes  to  absorb  more  readily  the  diphtheritic 
miasm. 

Sex. — Some  statistics  incline  the  balance  to  one  side,  while 
others  turn  it  toward  the  opposite.  Forgeot,  Bataille,  Bouillon 
Lagrange  and  Fourgeaud  have  observed  epidemic  diphtheria 
more  frequently  among  girls.  Jurine  regarded  croup  as  more 
frequent  among  boys.  Boudet  expresses  the  same  opinion. 
Vauthier  has  seen  diphtheria  attack  the  two  sexes  equally. 
Barthez  and  Rilliet  give  the  preponderance  to  the  male  sex, 
and  they  sustain  this  opinion  by  statistics  of  tracheotomy  made 
by  Trousseau  and  by  Jansecowitch  who  give  a  large  prepon- 
derance to  boys.  The  recapitulation  of  1,575  cases  of  diph- 
theria has  given  me  813  of  them  for  the  male  sex  and  762  for 
the  female.     These  statistics  made  upon  so  large  a  scale  in  the 


352  DIPHTHERIA,    CROUP    AND     TRACH  F.0'1  OM  Y. 

service  of  Barthez,  in  which  the  same  number  of  beds  is  as- 
signed to  boys  and  to  girls,  should  give,  so  far  as  statistics 
can,  an  idea  of  the  question  sufficiently  exact.  Though  the 
figures  for  the  boys  are  a  little  larger  than  those  for  the  girls, 
the  difference  of  5 1  cases  in  their  favor  has  but  little  signifi- 
cance, distributed  as  it  is  over  so  large  a  total.  It  appears,  then, 
that  diphtheria  extends  its  ravages  in  the  same  proportion  to 
each  sex.  Moreover,  it  would  be  useless  to  ask  why  it  pre- 
dominates over  one  or  over  the  other,  or  why  it  differs  in  this 
respect  from  the  eruptive  fevers. 

Teniperament. — Can  we  admit  that  diphtheria  develops  by 
preference  in  certain  temperaments?  Rilliet,  who  was  much 
occupied  with  this  question  admitted  that  the  lymphatic, 
tuberculous,  eczematous,  the  cancerous  temperaments  and  con- 
sanguinity constitute  predispositions  ;  Bouillon  Lagrange  has 
seen  in  73  patients,  57  lymphatics,  of  which  21  were  scrofulous. 
Signalized  by  authors  so  reputable,  these  cases  should  be 
taken  into  account.  I  have  a  number  of  times  met  with  diph- 
theria in  lymphatic  subjects,  but  also  in  many  others  who  were 
affected  with  different  diatheses  or  who  were  perfectly  free  in 
this  respect.  Diphtheria,  like  all  infectious  diseases,  may 
seize  upon  any  organism.  Nevertheless,  it  must  not  be 
forgotten  that  secondary  diphtheria  is  relatively  frequent,  and 
that  this  disease,  while  attacking  untainted  temperaments, 
affects  also,  and  perhaps  more  frequently  than  any  other  dis- 
ease of  the  same  class,  debilitated  constitutions.  I  have  been 
surprised  in  my  researches  in  secondary  diphtheria,  at  the  im- 
portant place  which  tuberculosis  holds  among  diseases  which 
are  followed  by  diphtheria.  It  is  not,  therefore,  impossible 
hat  all  conditions  of  organic  deterioration  render  the  soil  suit- 
able for  favoring  diphtheritic  germination.  Scrofula  may  have 
a  double  predisposing  action,  first  by  depressing  the  economy, 
and  then  by  the  facility  with  which  it  causes  inflammation  of 
the  mucous  membranes.  Likewise  the  eruptions  with  which  it 
covers  the  skin  often  serve  as  starting-points  to  ulcerations 
which  open  the  way  to  diphtheritic   invasion. 

On  the  other  hand,  when  the  disease    is   seen   to    extend    to 


DEVELOPMENT    OF    EPIDEMICS.  'i53 

entire  families,  to  certain  members  even  who  have  been  sepa- 
rated for  a  long  time  from  the  first  attacked,  may  one  not  ask 
whether  the  generalization  does  not  arise  by  virtue  of  the  con- 
sanguinity of  organization  which  unites  the  different  individ- 
ualities of  the  same  families,  a  conformity  which  would  place 
them  all,  respecting  diphtheria,  in  the  same  general  condition 
of  receptivity.  Not  every  person  exposed  to  diphtheritic  in- 
fection is  so  unfortunate  as  to  be  affected.  The  immunity  of 
some  persons  is  owing  to  these  individuals  not  presenting  the 
personal,  somatic,  quality  necessary  to  the  development  of  the 
disease. 

§  4 — Conditions  Unfavorable  to  the  Germ. 

Dry  climates,  elevated  localities,  seasons  regular  and  void 
of  dampness,  are  generally  unfavorable  to  the  germ.  Though 
the  latter  might  preserve  its  vitality  in  spite  of  these  condi- 
tions, it  is  none  the  less  true  that  epidemics,  developed  without 
this  influence,  are,  in  fact,  comparatively  quite  rare.  The  age 
of  the  germ  is  also  an  unfavorable  condition.  Although  this 
organism  may  remain  a  long  time  inactive,  in  a  kind  of  sleep, 
and  resume  afterwards  all  its  energy,  it  is  probable  that  the 
older  it  becomes  the  greater  are  the  probabilities  of  its  becom- 
ing altered  and  perishing. 

§  5.— Conditions  Unfavorable  to-  the  Receptivity. 

Of  these  adult  age  is  the  principal;  in  fact,  diphtheria  is 
rare  after  adolescence.  Also  good  hygienic  conditions  in  all 
that  concerns  the  dwelling,  alimentation  and  cleanliness.  As 
in  other  contagious  and  infectious  diseases,  pregnancy  seems 
to  confer  a  certain  immunity,  which,  however,  ceases  at  the 
the  time  of  delivery.  On  the  contrary,  females  recently  con- 
fined contract  diphtheria  with  facility.  Previous  contamina- 
tion is  not  a  sufficient  preventive  ;  it  is,  in  fact,  fully  demon- 
strated that  diphtheria  returns,  though  in  restricted  propor- 
tions. 

Secondary  Diphtheria. 

Diphtheria  most  frequently  attacks  healthy  individuals,  but 
it    intervenes     in    quite    a   large    number   of  diseases,    either 


354  DIPHTHERIA,  CROUP    AND    TRACHEOTOMV. 

during  their  course  or  following  them.  Many  authors  have 
been  impressed  with  this  coincidence.  Measles  have  been  sig- 
nalized as  an  antecedent  of  diphtheria  by  Barthez  and  Rilliet, 
West,  Trousseau,  Millard,  etc.;  scarlatina  by  Boudet,  Andre 
and  Peter;  small-pox,  by  Boudet;  varioloid,  by  Barthez  and 
Rilliet;  whooping-cough,  by  Finaz,  Vauthier  *and  Andre; 
typhoid  fever  by  Barthez  and  Rilliet,  Andre,  Oulmont,  etc.  In 
1,456  cases  of  diphtheria,  247  were  of  secondary  origin,  which 
gives  a  proportion  of  i  to  5.89. 

The  diseases  which  were  succeeded  by  diphtheria  are  in  the 
following  proportion : 

Measles,  -  137  cases         Pleurisy  -  4  cases 

Scarlatina    -         -       95       "  Tuberculosis  -   29     " 

Whooping-cough      -  20       "  Various  cachexiae  (scrofula. 

Typhoid  fever       -         8       "  chronic  diarrhea, etc.)  34  cases 

Small-pox        -         -    2      "  SyphiHs         -         -     3     " 

Urticaria       -         -         2       "  Purulent  ophthalmia  I      " 

Simple  bronchitis      -   4      "  Cholera         -         -      I     " 

Pneumonia   -         -        4      "  Doubtful  cases     -      3     " 


[An  error  in  the  original  figures].  347  cases. 

Measles,  in  this  table,  includes  the  largest  number  of  cases ; 
scarlatina  furnishes  considerably  less,  which  would  seem  to 
indicate  that  the  former  is  more  fruitful  in  diphtheria  than  the 
latter. 

This  would  be  an  error.  Scarlatina  furnishes  relatively  as 
many  as  measles ;  it  gives  occasion  to  even  a  larger  number. 
Its  apparent  inferiority  depends  upon  the  fact  that  it  is  much 
less  frequent  than  measles.  During  twenty  years,  1,453 
measles  cases  and  605  of  scarlatina  entered  the  service  of  Bar- 
thez. Diphtheria  consecutive  to  scarlatina,  has,  therefore, 
been  noted  95  times  in  605  cases,  that  is  i  in  6.  Consecutive 
to  measles  there  have  been  observed  137  in  1,453  cases,  that 
is,  I  in  10.  Consequently,  scarlatina  is,  of  all  diseases,  that 
which  is  most  frequently  followed  by  diphtheria.  Tuberculo- 
sis and  the  various  cachexias  hold  also  an  important  place 
among  the    diseases   which   prepare    the    way    for  diphtheria. 


DEVELOPMENT    OF    EPIDEMICS.  35  5 

These  diseases  may  be  divided  into  two  groups  respecting 
their  action  on  diphtheria.  The  first,  hke  cachexiae,  appear 
to  prepare  for  it  the  soil,  as  they  do  for  all  specific  diseases,  by 
debilitating  the  economy  and  diminishing  its  power  of  resis- 
tance to  miasmatic  absorption.  The  others  appear  to  have 
a  quite  special  affinity  for  diphtheria.  These  are,  like  it,  spe- 
cific diseases;  measles,  scarlatina,  whooping  cough,  typhoid 
fever  and  tuberculosis.  These  diseases  do  not,  strictly  speak- 
ing, engender  diphtheria ;  they  open  a  broad  access  for  it. 
Their  preparatory  action  is  twofold;  they  act,  first,  like  the 
preceding,  by  depressing  the  organism  and  by  rendering  it 
liable  to  contract  any  contagious  disease,  principally 
that  which  prevails  at  the  time.  But  they  also  cause 
the  economy  to  undergo  an  important  local  preparation.  I 
have  several  times  insisted  upon  the  important  role  which  in- 
flammation of  various  mucous  membranes  plays,  in  respect  of 
the  genesis  of  diphtheria.  Now,  all  these  diseases  have  a 
strong  attraction  on  the  part  of  the  guttural  and  respiratory 
mucous  membranes.  It  is,  therefore,  very  plain  that  diph- 
theria may  be  strongly  attracted  to  the  organs  so  much  dis- 
posed to  receive  it.  In  studying  the  symptoms  of  secondary 
diphtheria  I  have  showed  that  it  preserves  the  stamp  of  the 
primary  disease;  its  local  manifestations  nearly  always  coincide 
with  those  of  the  disease  which  has  prepared  the  way  for  it. 
That  which  follows  measles  and  whooping-cough,  prefers  the 
respiratory  apparatus ;  that  which  succeeds  scarlatina  selects 
by  preference  the  throat.  Though  less  striking,  these  pecu- 
liarities are  found  in  all  the  diseases  which  precede  diphtheria. 
It  is  not  only  during  their  period  of  acme  that  these  morbid 
conditions  attract  diphtheria ;  they  still  preserve  this  power 
during  convalescence.  These  things  occur  exactly  the  same  ; 
the  organs,  still  under  the  influence  of  crises  which  they  have 
suffered  during  the  first  period,  conduct  themselves  in  the 
same  manner  in  the  presence  of  diphtheria. 

INCUBATION    OF    DIPHTHERIA. 

In  order  to  estimate  accurately  the  duration  of  diphtheritic 
incubation  it  is  necessary  to  know  the  exact  moment  at  which 


356  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

contact  is  effected.  Inoculation  or  the  deposit  of  morbific 
matter  upon  the  mucous  membrane  alone  offers  precise  data. 
Experimental  inoculation  failing,  and  accidental  inoculation 
being  contestable,  there  is,  therefore,  occasion  for  taking  into 
consideration  the  results  furnished  by  placing  the  mucous 
membranes  in  contact  with  diphtheritic  products.  These  are 
presented  under  conditions  of  careful  experimentation.  In  the 
experience  of  Trendelenburg,  incubation  has  been  from  one  to 
two  or  three  days;  in  those  of  L.  Lagrave  of  about  twenty  hours; 
in  those  of  Duchamp  it  was  from  twenty-four  to  thirty-six 
hours,  for  the  animal  died  at  the  end  of  two  days,  having  the 
larynx  and  the  trachea  covered  with  false  membranes,  and  the 
lungs  hepatized. 

The  small  number  of  experiments,  it  is  true,  allows  of  a 
variation  between  twelve  hours  and  three  days,  as  the  duration 
of  diphtheritic  incubation.  It  is  well  to  observe  that  in  the 
case  of  accidental  inoculation  cited  by  Dr.  Bonnet,  the  incuba- 
tion was  one  day.  This  agreement  proves  once  more  the 
reality  of  inoculation  under  these  circumstances.  Before  com- 
prehending these  facts,  one  endeavored  to  attain  the  same  end 
by  seeking  the  time  which  intervened  between  the  presumed 
contact  and  the  period  when  the  symptoms  arose.  For  exam- 
ple, a  person  remains  several  hours  in  contact  with  a  diphthe- 
ritic patient.  At  the  end  of  a  few  days  he  is  taken  with  diph- 
theritic angina.  Everything  tends  to  the  belief  that  we  know 
the  duration  of  the  incubation.  Another  example:  a  patient 
with  this  disease  enters  a  ward  free  of  diphtheria  ;  a  few  days 
pass,  and  cases  of  diphtheria  break  out  among  the  patients  pre- 
viously admitted  for  other  diseases,  or  among  the  convalescents. 
In  the  first  class  of  facts  the  problem  Is  very  simple ;  in  the 
second  it  becomes  more  difficult,  if  several  cases  occur  succes- 
sively, but  near  together.  If  we  may  flatter  ourselves  that  we 
know  the  duration  of  the  incubation  in  the  first  patient,  it 
becomes  very  difficult  to  know  at  what  moment  the  third  was 
contaminated.  Positive  data  fail  absolutely.  We  resign  our- 
selves to  approximations,  and  are  content  with  obtaining  the 
maximum  duration.     Suppose  that  three   cases  of  diohtheria 


DEVELOPMENT    OF    EPIDEMICS.  357 

appear  in  a  ward,  four,  five  or  six  days  after  the  entrance  of  an 
infected  patient,  one  might  say  that,  in  the  first  case,  incuba- 
tion lasted  four  days ;  for  the  others  one  may  affim  that  it  does 
not  exceed  more  than  five  or  six  days,  but  it  is  impossible  to 
know  whether  it  was  shorter.  We  need  not  look  for  anything 
but  the  maximum  of  the  incubation. 

But  while  these  figures  may  be  obtained  when  the  facts 
occur  isolatedly  in  a  family,  in  a  circumscribed  place,  or  in  a 
ward  of  a  hospital  still  uninfected,  we  conceive  that  in  times 
of  epidemics  the  dispersion  of  morbific  germs  in  the  atmos- 
phere produces  constantly  cases  of  infection  in  which  it  may  be 
impossible  to  apprehend  the  moment  of  contamination.  If,  in 
those  conditions,  a  person  healthy  in  appearance,  enters,  for 
any  disease  whatever,  one  of  the  hospital  wards  where  diph- 
theritic patients  are  found,  and  at  the  end  of  a  few  days  he 
should  be  himself  attacked  with  diphtheria,  there  is  nothing  to 
prove  that  he  may  have  acquired  in  the  hospital  the  germ  of 
the  disease.  Perhaps  he  may  have  received  it  from  one  of 
those  limited,  often  undiscovered,  infected  centers  of  the  large 
cities.  Investigation  should  be  limited  necessarily  to  isolated 
cases,  or  to  the  beginning  of  the  epidemic.  Roger  has  con- 
cluded from  the  examination  of  seventeen  cases,  that  the  max- 
imum of  the  duration  of  incubation  might  be  represented  ap- 
proximately by  a  period  of  from  two  to  seven  days.  Peter 
reached  figures  almost  the  same,  by  researches  conducted  in  a 
similar  manner.  The  approximate  incubation  may  be,  most 
frequently  from  two  to  eight  days  ;  exceptionally  it  might  be 
from  twelve  to  fifteen.  Dr.  Mair,  in  the  account  which  he 
gives  of  the  epidemic  which  he  observed  in  Middle  Franconia, 
assigns  to  this  peried  an  average  duration  of  from  eight  to  ten 
days.  In  some  cases  it  may  have  been,  he  says,  even  from 
four  to  six  weeks.  This  last  limit  shows  the  embarrassment  in 
which  the  author  found  himself  in  the  presence  of  cases  de- 
veloped in  patients  who  were  in  contact  for  a  long  time  with 
infected  centers  of  diphtheria.     The  results  which  I   have  ob- 


358  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

tained  differ  but  little.     In  98  cases  incubation  seems  to  have 
had  the  following  duration  : 

From  I  to  2  days  7  cases     From  13  to  15  days        6  cases 

From  2  to  8  days        48  cases     From  15  to  20  days      14  cases 

From  8  to  13  days      23  cases  

Total         -----  -_q8  cases 

These  results  differ,  evidently,  from  those  of  experiments,  as 
we  might  presume  would  be  the  case  in  the  absence  of  exact 
documents.  The  evidence  was  demonstrated  in  several  cases  ; 
we  find,  in  fact,  in  all  the  tables,  a  certain  number  of  cases  in 
which  incubation  does  not  exceed  two  days.  For  others,  and 
especially  for  those  in  which  this  period  reaches  fifteen  or 
twenty  days  and  more,  there  were  very  likely  mistakes.  It  is, 
therefore  necessary  in  awaiting  more  numerous  observations, 
to  accept  the  figures  furnished  by  experiment  and  to  recognize 
in  diphtheritic  incubation  a  probable  duration  of  from  one  to 
three  days,  with  the  possibility  of  its  extending  somewhat  be- 
yond these  limits. 


THE  NATURE  OF  DIPHTHERIA. 


In  several  chapters  of  this  work  I  have  given  my  explana- 
tion of  the  nature  of  diphtheria,  and  everywhere  I  have  invoked 
the  principle  of  specificity.  The  propositions,  laid  down  here 
and  there  according  to  the  necessities  of  the  discussion,  should 
be  united  into  a  body  which  represents  the  doctrinal  sum  total 
ot  diphtheria.  It  is  to  Bretonneau  that  the  honor  belongs  of 
having  established  the  specific  character  of  diphtheria,  at  the 
same  time  that  he  proved  the  ontological  identity  of  the 
pseudo-membranous  angina  and  croup.  Popularized  by  the 
mighty  dictum  of  Trousseau,  this  conception  was  completed 
by  Barthez.  By  showing  that  infectious  croup,  and  the  disease 
designated  by  the  name  of  simple  croup,  or  common  croup,  were 
but  different  degrees  of  the  same  poison,  viz.,  diphtheria,  my 
eminent  and  cherished  preceptor  brought  to  bear  a  new  argu- 
ment of  great  value  in  favor  of  the  identity  in  nature  of  the 
different  membranous  affections.  The  discussions  which  took 
place  at  the  same  time  in  the  Academy  of  Medicine  and  in  the 
Societe  des  hopitaux,  and  in  the  works  of  Peter,  Hervieux 
and  others  contributed  to  the  further  confirmation  of  that 
view.  A  general  disease,  specific,  infectious,  contagious,  ca- 
pable of  localizing  itself  upon  the  most  various  points,  adopt- 
ing variable  anatomical  forms  according  to  its  region  and  pro- 
ducing numerous  visceral  lesions,  such  is  the  primary  idea  of 
the  doctrine. 

Another  point  not  less  important,  established  by  Breton- 
neau, is  the  exudative  character  of  diphtheria  of  which  he 
makes  a  specific  phlegmasia,  and  which  he  distinguishes  ab- 
solutely from  gangrene,  claiming  that  the  mucous  membrane 
is  always  healthy  underneath  the  false  membrane.  That  con- 
clusion was  too   absolute,  as  the    observations    published   by 

(359) 


360  DIPHTHERIA,    CROUP    AND    TRACHKOTOMV. 

Becquerel,  Barthez  and  Rilliet,  and  Empis  and  Isambert 
showed.  Trousseau  also  had  to  modify  the  ideas  of  his  pre- 
ceptor wherein  they  were  extreme.  Grounding  himself  upon 
the  well  known  existence  of  gangrene  in  other  specific  dis- 
eases, as  measles,  scarlatina,  small-pox,  etc.,  he  admits  that 
gangrene  of  the  pharynx  may  be  an  expression,  rare  indeed, 
but  genuine,  of  the  diphtheritic  poison. 

I  fully  accept  this  view.  Diphtheria  is,  to  my  mind,  a  dis- 
ease which  is  toiitis  substaiiticB  primarily  general.  All  its  forms, 
so  diverse  in  appearance,  are  but  different  manifestions  of  a 
single  cause  which  contaminates  the  whole  economy.  It 
should  be  placed  in  the  nosological  list  beside  those  diseases 
whose  manifestations  are  multiple  in  spite  of  the  unity  of  the 
cause,  such  as  measles,  scarlatina,  small-pox  or  syphilis.  The 
major  part  of  French  physicians  regard  diphtheria  in  this  light, 
nevertheless,  disagreements  exist  upon  certain  points.  Ac- 
cording to  some  physicians,  the  disease  is  local  at  first,  and 
becomes  general  only  by  the  absorption  of  prodncts  which 
arise  from  the  alteration  of  the  false  membranes.  Others,  hold- 
ing as  null  and  void  the  works  of  Bretonneau  and  of  his  suc- 
cessors, put  science  back  to  the  point  where  Home  left  it.  In 
other  words  they  make  two  different  diseases  of  croup  and 
angina  gangrenosa.  This  is  the  German  notion  of  diphtheria. 
Let  us  examine  these  two  theories. 

First  Theory. — The  local  origin  of  diphtheria  has  been 
supported  in  modern  times  by  Bretonneau  and  by  Trousseau, 
while  Bouchut  is  still  one  of  its  few  defenders. 

"There  is,  however,"  says  Trousseau,  "an  essential  difterence  to  be  laid  down 
between  diphtheria  and  the  diseases  which  we  have  just  named,  (small-pox,  measles, 
syphilis);  it  is,  that  in  the  former,  we  must  take  the  local  affection  into  account  more 
than  in  the  latter.  So,  in  small-pox,  for  example,  we  do  not  preoccupy  ourselves 
with  the  pus'ules,  at  least,  we  do  not  preoccup  yourselves  with  them  except  in  view  of 
the  prognostic  or  diagnostic  nieanin,;,'-  we  can  draw  from  them.  If  we  do  not  preoccupy 
ourselves  with  them  from  the  standpoint  oi  treatment,  it  is  no  longer  so  in  diph- 
theria. What  lakes  place  here,  may  be,  in  fact,  compared  with  what  occurs  in  mal- 
ignant pustule,  in  which  by  directly  attacking  the  local  affection,  we  ward  off  the 
general  disease  of  which  that  affection  was  a  primary  manifestation.  So,  also,  in 
diphtheria,  by  interfering  energetically  to  combat  the  first  manifestation,  we  are 
sometimes  able  to  arrest  its  progress  and  prevent  its  later  manifestations." 

From  this  comes  the  supreme  importance  which  Trousseau, 
like  Bretonneau,  ascribed   to  cauterization   of  the   false  mem- 


NATURE    OF     DIPHTHERIA.        ^  3^^ 

branes,  and  from  this,  according  to  Bouchut,  arises  the  utility 
of  amputating  the  tonsils    covered  with  false  membrane. 

The  experience  of  these  latter  years  will  not  allow  the  ac- 
ceptance of  that  view.  In  the  chapter  on  Treatment,  the  re- 
markable unanimity  of  practitioners  with  regard  to  the 
uselessness  of  cauterization  in  diphtheria  will  be  shown.  It 
will  also  be  seen  that  amputation  of  the  tonsils  has  not  re- 
sponded to  the  expectation  of  its  author,  for  it  has  not  pre- 
vented, in  many  cases,  the  extension  of  diphtheria,  and  in 
others,  as  I  have  witnessed,  diphtheria  has  returned  even  upon 
the  surface  of  the  cut. 

On  the  other  hand,  the  comparison  which  Trousseau  laid 
down  between  diphtheria  and  malignant  pustule,  is  no  longer 
acceptable.  In  fact,  while  malignant  pustule  is  a  species  of 
parasitic  nidus  the  bacteria  of  which  escape  to  penetrate  little 
by  httle  into  the  blood,  and  in  such  a  manner  that  when  the  lair 
is  destroyed  the  infection  ceases,  the  false  membranes  are,  on 
the  contrary,  the  proof  of  a  general  infection.  They  can  be 
more  justly  compared  to  the  indurated  chancre  which  develops 
at  the  very  point  where  the  virus  has  penetrated  the  economy, 
but  which  is,  in  reality,  the  first  of  the  secondary  accidents. 
There  is  to-day  no  physician  who  pretends  to  arrest  the  course 
of  syphilis  by  excising  or  cauterizing  the  chancre.  This  re- 
semblance between  diphtheria  and  malignant  pustule  is  still 
less  acceptable  as,  according  to  all  probability,  the  penetration 
of  the  diphtheritic  poison  into  the  economy  takes  place 
through  the  respiratory  passages,  viz.,  the  nose,  the  pharynx,  the 
larynx,  etc.;  and  the  cases  where  it  is  said  to  have  been  intro- 
duced through  a  solution  of  continuity,  are  very  rare  and  are 
contested.  If  diphtheria  were  a  local  disease  at  first,  beginning 
at  the  tonsils,  and  became  general  afterwards  only  by  absorp- 
tion, what  organs  would  be  more  exposed  to  the  reception  of 
the  poison  of  the  disease,  than  the  digestive  tract  which  is  in 
habitual  contact  with  the  debris  of  the  false  membranes,  swal- 
lowed together  with  the  saliva  and  with  food,  if  they  are  not 
constantly  bathed  in  an  ichorous  fetid  liquid  which  proceeds 
from  the  fauces.     Notwithstanding  these  conditions  so  favora- 


362  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

ble  to  the  development  of  false  membranes,  their  presence  in 
the  oesophagus,  the  stomach  and  the  intestine  is  exceptional. 
Another  argument  may  be  opposed  to  this  theory,  and  that  is 
the  existence  of  cases  in  which  angina  and  croup  were  consec- 
utive to  diphtheria  of  the  skin.  In  those  cases  pharyngo-lar- 
yngeal  false  membranes  have  been  seen  to  develop  secondarily. 
The  mechanism  indicated  by  the  partisans  of  secondary  poi- 
soning is  inapplicable  to  tnese  tacts. 

Is  there  not  also  an  imposing  number  of  patients  with  whom 
the  generalization  of  the  false  membranes  comes  on  with  such 
rapidity  that  these  products  are  seen  to  arise  on  all  sides 
almost  at  the  same  time  ?  How  could  the  economy  have 
become  infected  by  the  first  which  appeared,  which,  moreover, 
had  not  had  time  to  become  decomposed?  What  does  that 
very  alteration  prove,  except  the  intensity  of  the  blood  poison- 
ing ?  The  most  generalized  forms  are  not  those  in  which  the 
false  membranes  become  most  decomposed ;  it  is  rather  the 
opposite  which  is  observed.  The  tendency  toward  putrefac- 
tion, is  met  especially  in  the  forms  where  profound  poisoning 
coincides  with  a  localized  production  of  false  membrane  ;  and 
it  is  often  lacking  in  generalized  diphtheria.  But,  it  will  be 
said,  the  symptoms  of  infection,  absent  at  first,  sometimes  ap- 
pear only  after  a  certain  time,  which  proves  that  the  poisoning 
is  indeed  secondary.  To  this  I  will  reply  that  it  is  fully  as 
common,  if  not  more  so,  to  find  the  diphtheritic  poisoning  ev- 
ident from  the  first,  and  that  these  are  the  cases  which  are 
most  intense  that  begin  thus  ;  that  the  false  membrane  is  then 
but  an  unimportant  element,  and  that  we  have  seen  patients 
succumb  in  a  few  hours,  whose  every  apparent  lesion  was  only 
an  insignificant  false  membrane. 

These  facts  are  a  confirmation  of  a  precept  which  I  have  en- 
deavored to  make  clear.  It  is  impossible  to  establish  a  constant 
correspondence  between  the  character  of  the  false  membrane  and 
the  degree  of  diphtheritic  poisoning.  There  are  often  seen  thin, 
discrete  false  membranes  which  could  be  easily  taken,  and 
which  have  been  too  often  taken  for  herpes  of  the  pharynx, 
accompanied  by  general  symptoms  of  great   gravity  and  re- 


NATURE    OF    DIPHTHERIA.  363 

suiting  at  last  in  death.  On  the  contrary,  it  is  not  rare  to  see 
large  and  extended  false  membranes,  occupying  the  whole 
fauces,  give  rise  to  an  almost  imperceptible  reaction  and  allow- 
ing of  cure,  provided  always  that  they  do  not  bring  on  death 
by  a  purely  mechanical  process,  viz.,  by  penetrating  into  the 
larynx. 

Now,  can  it  be  said  that  the  false  membranes  do  not 
undergo  alteration,  or  that  such  alteration  is  without  disadvan- 
tage ?  Evidently  not.  They  do  undergo,  in  severe  cases,  a 
tfue  putrefaction  which  to  the  first  poisoning  adds  a  second. 

These  two  are  of  very  different  nature.  The  pus,  the  altered 
blood  and  the  fetid  ichor  which  is  discharged  in  great  abund- 
ance, whether  absorbed  by  the  digestive  mucous  membrane  or 
by  the  denuded  surfaces,  are  a  new  element  of  infection,  not 
of  diphtheritic  infection,  however,  but  of  infection  by  septic 
products  ;  in  other  words,  of  putrid  infection,  or  of  septicaemia. 

The  conclusion  from  this  discussion  is  that  the  false  mem- 
branes are  the  effect  and  not  the  cause  of  the  diphtheritic 
poisoning,  and  consequently  their  destruction  is  practically  of 
secondary  importance,  so  long  as  their  alteration  and  their 
locality  do  not  give  rise  to  special  indications. 

Second  Theory. — This  is  the  German  anatomical  theory 
which  I  have  analyzed  in  detail  in  the  chapter  on  Pathological 
Anatomy.  Preoccupied  first  of  all,  with  solving  the  question 
of  specificity  by  means  of  pathological  anatomy,  Virchow's 
school  distinguished  two  kinds  of  pseudo-membranous  affec- 
tions. One  is  croup,  a  superficial  exudation  formed  upon  the 
surface  of  the  mucous  membranes  or  of  the  denuded  skin,  leav- 
ing the  chorion  of  the  mucous  membrane  intact,  and  seated 
upon  the  respiratory  mucous  membrane.  The  other  is  diph- 
theria, an  interstitial  infiltration  formed  in  the  substance  of  the 
chorion  of  the  mucous  membrane  or  skin,  which  results  in  the 
death  of  the  tissues  which  it  infiltrates.  Its  product  is  nothing 
else  than  a  true  eschar,  and  behaves  in  like  manner.  This 
process  is  seated  in  the  pharynx. 

All  diseases  which  presented  a  fibrinous  exudation  as  a 
lesion,  were   classed    in   these  two    lists,   and    became    either 


364  DIPHTHERIA,  CROUP  AND  TRACHEOTOMY. 

croupous  or  diphtheritic.  Fibrinous  pneumonia  became  croupous 
pneumonia,  etc.;  dysentry,  hospital  gangrene,  ulcero-mem- 
branous  stomatitis,  etc.,  became  diphtherias  under  the  same 
head  as  pseudo -membranous  pharyngitis. 

Conceived  in  these  terms,  and  adapting  to  anatomical 
processes,  names  which  had  hitherto  served  to  designate  symp- 
tomatic groups,  this  classification  of  necessity  brought  in  a 
most  fantastic  confusion.  Ignoring  the  teachings  of  the  clinic 
and  under  the  pretext  that  early  observers,  such  as  Michaelis, 
Albers,  Jurine  and  Vieusseux,  had  before  their  eyes  simple 
croup  which  they  regarded  as  non-  contagious,  and  which  is 
rarely  accompanied  by  pharyngitis,  an  anatomical  croup  was 
discovered,  an  inflammatory  disease  limited  exactly  to  the 
respiratory  passages.  Diphtheritic  pharyngitis  alone  remained 
the  general  and  contagious  disease.  But  what  was  to  be  done 
with  those  cases  in  which  the  pharyngitis  and  the  croup  existed 
together?  To  this  question  Wagner  answered  that  in  the 
same  patient  there  might  exist,  side  by  side,  and  probably  by 
mere  accident,  a  diphtheria  of  the  pharynx  and  of  the  supra- 
glottidean  portion  of  the  larynx,  a  general,  contagious  disease, 
and  a  croup  of  the  lower  portion  of  the  larynx,  of  the  trachea 
and  of  the  bronchi,  a  disease  purely  local  and  non  contagious. 

Without  speaking  of  the  flagrant  error,  from  a  clinical  point 
of  view  which  this  theory  contains,  its  principal  support  does 
not  rest  upon  a  solid  basis.  I  have  endeavored  to  show  that 
the  results  obtained  by  Virchow  and  his  school  were  erroneous. 
I  have  been  aided  in  that  task  by  German  observers  themselves 
who  have  arrived  at  entirely  different  conclusions  from  their 
predecessors. 

One  of  the  arguments  which  serves  to  bolster  up  the  ana- 
tomical croup  of  the  Germans,  is  the  existence  of  a  localized 
croup,  which  also  appeared  non-contagious,  noted  by  the  early 
authors. 

These  cases  should  not  be  denied.  We  know  this,  and  it  is 
a  point  to  which  I  have  often  called  attention,  that  diphtheria 
sometimes  presents  light  manifestions  only,  in  which  the  local 
affection  seems  to  prevail  exclusively,  and   in  which   the    con- 


NATURE    OF    DIPHTHERIA.  3^5 

tagious  power  seems  doubtful;  but  side  by  side  with  these 
cases,  do  we  not  see  the  gradation  which  insensibly  rises  from 
that  attenuated  form  to  the  gravest  forms  characterized  by  in- 
vasion of  the  air-passages  throughout  their  entire  extent,  by 
generalization  of  the  false  membranes  and  by  gangrene  of  the 
mucous  membrane  ? 

Is  it  necessary,  in  order  to  show  the  foolishness  of  this  class- 
ification, to  notice  the  resemblance  which  it  asserts  between 
diphtheria,  dysentery,  hospital  gangrene  and  ulcero-mem- 
branous  stomatitis,  diseases  which  are  absolutely  distinct  there- 
from ?  And  for  that  matter,  if  there  is  a  disease  which 
anatomically  is  a  diphtheria  in  the  German  sense  that  is  ulcero- 
membranous stomatitis ;  it  is  even  much  more  diphtheritic 
than  diphtheritic  pharyngitis  itself.  Who  would  dream  to-day 
of  establishing  a  relationship  between  these  two  diseases  ? 
Moreover,  even  in  Germany  they  have  begun  to  return  to  the 
ideas  which  the  clinic  teaches,  for,  in  a  discussion  which  took 
place  at  Berlin  in  1872,  in  the  Medical  Society,  although  Dr. 
Waldenberg  persisted  in  discriminating  croup  from  diphtheria. 
Professor  Traube  declared  that  any  clinical  distinction  between 
croup  and  diphtheria  was  impossible.  To  his  mind  diph- 
theria is  a  unit,  but  its  products  may  be  various  ,  some  being 
interstitial  and  ending  in  gangrene,  while  others  are  superficial 
and  are  like  catarrh.  This  is,  as  we  see,  a  complete  return  to  the 
doctrine  of  Bretonneau.  Like  all  the  other  physicians  present 
at  the  discussion.  Professor  Traube  had  renounced  cauterization 
because  of  its  inefficiency. 

This  communication  is  all  the  more  valuable  because  Traube, 
one  of  the  most  illustrious  physicians  in  Germany,  has  been 
the  admirer  and  the  successor  of  Schonlein,  the  principal  de- 
fender, together  with  Virchow,  of  the  local  nature  of  croup. 

At  Vienna  there  is  the  same  divergence  of  opinion.  Oppol- 
zer  was  still  in  1868  proclaiming  the  difference  between  the 
nature  of  croup  and  diphtheria. 

Professor  Skoda,  on  the  contrary,  declares  distinction  impos- 
sible at  the  bedside.  He  says  that  at  Vienna,  croup,  whether 
primary  or  secondary,  sporadic  or  epidemic,  is  almost  always 
preceded  by  a  membranous  pharyngitis. 


366  DIPHTHERIA,    CROUP  AND    TRACHEOTOMY, 

The  identity  of  croup  and  diphtheritic  angina,  for  a  time 
placed  in  doubt,  is  thus  almost  generally  recognized,  as  the 
judicious  observation  of  facts  demands.  To  assimilate  diph- 
theria completely  to  general  diseases,  one  question  still  re- 
mains for  solution,  viz.,  can  diphtheria,  side  by  side  with  severe 
forms,  assume  benign,  attenuated  forms  which  nevertheless 
belong  to  its  domain?  That  question  seems  to  be  solved  as 
soon  as  stated.  Every  disease  has  its  degrees.  Barthez  was 
one  of  the  first  to  insist  on  this  point.  He  proved  the  existence 
by  the  side  of  severe  and  well  characterized  cases,  of  milder 
ones,  which  could  not  always  be  referred  to  their  real  cause, 
unless  the  positive  fact  were  kept  in  view  which  revealed  their 
nature.  Yet  this  truth  has  been  contested,  and  only  such 
cases  have  been  willingly  considered  as  belonging  to  diph- 
theria, as  had  formidable  local  lesions  and  an  evident  infection. 
It  often  happens  that  benign  and  discrete  forms  are  set  apart 
under  the  name  of  herpetic  pharyngitis  or  common  membra- 
nous sore  throat.  The  differentiation  has  been  given  under 
the  head  of  diagnosis. 

It  must  be  considered  that  the  process  has  by  virtue  of  indi- 
vidual conditions  been  arrested  in  its  evolution.  The  early 
authors  naturally  compared  the  disease  to  a  seed  deposited 
in  a  soil,  which  is  the  patient.  If  the  soil  be  favorable,  and  the 
surrounding  circumstances  be  propitious,  germination  takes 
place,  a  new  entity  is  born  and  grows.  But  all  soils  do  not 
favor  the  growth  of  the  same  germ.  If  the  latter  be  deposited 
upon  an  unfavorable  soil  it  dies  or  is  incompletely  developed. 
This  is  what  happens  in  contagious  diseases,  and  it  explains 
why  all  subjects  exposed  to  contagion  do  not  take  the  disease 
with  the  same  intensity,  or  even  may  escape  it.  This  compar- 
ison is  more  applicable  than  ever  in  our  day  when  the  tenden- 
cy is  to  assign  a  very  important  role  in  the  production  of  dis- 
ease to  inferior  organisms,  such  as  spores,  bacteria,  etc. 

This  arrest  of  development  is  not  peculiar  to  diphtheria. 
Docs  scarlatina  cease  to  be  scarlatina  because  the  exanthema 
may  have  been  light  or  fugacious,  or  because  it  may  have  been 
wanting?     Do  not  the  cases  where  the  general  symptoms  are 


NATURE    OF    DIPHTHERIA.  367 

insignificant,  belong  to  scarlatina  as  well  as  those  which  are 
announced  by  a  formidable  ataxia?  Are  not  discrete  and  con- 
fluent variola  and  modified  variola  or  varioloid,  varieties  of  the 
same  disease  ? 

How  many  degrees  are  there  in  typhoid  fever,  from  the  ful- 
minant ataxic  form  to  the  walking  form?  Do  not  measles, 
puerperal  fever,  and  other  specific  diseases  behave  in  like  man- 
ner ?  Is  not  cholera,  even  during  epidemics,  limited  to  a  pro- 
fuse diarrhoea  in  a  great  number  of  subjects? 

Beside  these  arguments  which  analogy  furnishes,  in  favor  of 
the  identity  of  the  different  manifestations  of  diphtheria,  there 
are  found  others  in  the  fact  of  the  coexistence  in  times  of  epi- 
demic, of  localizations  the  most  varied  as  to  site  and  intensity, 
and  especially  of  their  mutual  transformation.  Examples  are 
not  wanting  of  cases  of  benign  pharyngitis  coinciding  in  the 
same  places  and  in  the  same  families  with  cases  of  severe 
pharyngitis.  We  have  also  proof  of  the  contagiousness  of  the 
most  simple  manifestations,  and  they  do  not  confine  themselves 
to  transmitting  the  disease  with  inoffensive  characteristics,  but 
a  benign  diphtheria  often  communicates  a  severe  diphtheria 
and  vice  versa.  The  facts  sited  by  Vigla,  by  Guerard  and  by 
Peter,  present  benign  diphtheria  as  communicating  forms 
sometimes  simple,  and  sometimes  malignant,  just  as  varioloid 
transmits  discrete  or  confluent  small-pox  indifferently.  On  the 
other  hand,  malignant  diphtheria  appears  there,  susceptible  of 
becoming  in  other  subjects  transformed  into  benign  diphtheria. 
The  communication  of  Vigla  shows  us  a  case  of  transmission 
which  is  likewise  curious.  A  babe  of  twenty  months  suc- 
cumbed to  a  cutaneous  diphtheria  developed  after  vesication. 
Three  days  before  it  died  the  father  of  the  child  made  a  slight 
abrasion  upon  one  of  his  great  toes,  and  a  false  membrane  de- 
veloped upon  it  rapidly  and  invaded  a  portion  of  the  toe.  At 
the  same  time  the  patient  complained  at  two  different  times  of 
pain  in  the  fauces,  together  with  general  malaise ;  but  the  most 
careful  examination  did  not  discover  a  single  false  membrane  in 
the  fauces. 

Recovery  took  place.     At  the  same  time,  i.  e.,  two  days  be- 


368  DIPHTHERIA,  CROUP    AND    TRACHEOTOMY. 

fore  the  death  of  the  same  child,  the  mother  was  attacked  with 
a  sHght  diphtheritic  pharyngitis  which  recovered  in  nine  days. 
The  very  night  before  the  day  when  the  mother  fell  sick  a  lit- 
tle girl  of  4  years — her  other  child — was  taken  with  a  vulvar 
diphtheria  which  recurred  and  made  way  for  a  croup  without 
pharyngitis  which  rapidly  carried  off  the  patient.  Thus 
in  these  four  persons  who  composed  this  family,  every  one  of 
whom  was  attacked,  the  diphtheria  assumed  a  benign  form 
with  two  of  them,  and  a  severe  form  with  the  other  two. 

Guerard  witnessed,  in  another  family,  just  as  interesting 
facts  which  developed  themselves  for  six  weeks.  A  child  led 
the  series  and  succumbed  to  croup.  Two  girls  were  taken 
two  days  afterwards  with  simple  erythematous  sore  throat. 
Some  days  later  the  father  had  a  pseudo-membranous  phar- 
yngitis. Finally  the  two  remaining  children  were  attacked, 
after  him,  one  with  simple  sore  throat  and  the  other  with 
membranous  sore  throat.  Thus — one  croup,  three  erythematous 
sore  throats  and  two  membranous  sore  throats  were  obser\'ed 
successively  in  persons  all  of  the  same  family. 

The  observation  cited  by  Peter  shows  analogous  facts.  In 
seven  persons  with  the  same  surroundings,  parents,  friends  and 
domestics,  there  were  seen  one  little  girl  of  two  months  suc- 
cumbing to  a  membranous  sore  throat,  the  mother  attacked 
the  night  before  the  death  of  the  child  with  a  membranous 
sore  throat  and  with  diphtheria  of  the  nipple.  She  recovered. 
The  nurse  who  took  care  of  the  little  girl  was  taken  with  a  se- 
vere erythemato7is  sore  throat.  Its  father,  grandfather,  and 
mother  had  simple,  medium,  or  benign  sore  throats.  A  neigh- 
boring woman  who  often  came  to  visit  the  sick  suffered  from  a 
simple   laryngitis.     The  cook  escaped  entirely. 

I  cited,  when  treating  of  the  diagnosis,  another  observation 
which  showed  a  sore  throat, considered  as  herpetic, transmitting 
a  fatal  croup,  which  communicated  to  Gillette  the  generalized 
diphtheria  to  which  he  succumbed. 

Barthez  has  kindly  reported  to  me  an  instance  of  the  same 
kind  which  he  witnessed  as  consulting  physician.  In  a  family 
consisting    of    father,   mother,   one  child  and  a   servant,    the 


NATURE    OF    DIPHTHERIA.  3^9 

child,  aged  two,  was  taken  with  a  severe  diphtheritic  coryza. 
The  family  physician,  under  the  belief  that  it  would  act  favor- 
ably upon  the  coryza,  applied  a  vesicant  upon  the  back  of  the 
neck,  which  became  covered  with  false  membrane.  The  child 
died  without  any  manifestations  on  the  part  of  the  fauces  or  of 
the  larynx.  The  other  parties  had  attended  the  little  patient 
with  the  greatest  devotion,  carrying  it  incessantly,  for  it  would 
not  remain  in  bed,  and  were  constantly  exposed  to  contact  of 
its  face  with  theirs.  The  mother  took  a  coryza  of  the  same  na- 
ture, of  moderate  intensity,  and  recovered  without  any  other 
manifestation.  The  father  also  had  a  coryza  of  the  same  kind, 
but  very  light  and  characterized  only  by  a  false  membrane  oc- 
cupying the  opening  of  the  nostrils.  In  the  servant  there  ap- 
peared an  intense  pharyngitis  but  without  false  membranes. 
Like  instances  have  been  produced  by  Beaupoil,  Laboulbene, 
Bricheteau,  and  Morax.  Such  examples  clearly  prove  the  ex- 
istence of  a  benign  diphtheria.  Why  not  admit  as  diphtheri- 
tic, those  light  pseudo-membranous  affections  contracted  in 
centers  infected  with  diphtheria,  and  taken  in  contact  with  the 
•least  doubtful  and  gravest  diphtheritic  manifestations?  Four- 
geaud  observed  a  great  number  of  these  reductions  (mild 
examples)  in  the  epidemic  of  which  he  gave  an  account. 

Should  these  sore  throats,  arising  in  the  midst  of  the  epi- 
demic focus,  in  company  with  pseudo-membranous  sore  throats 
of  decreasing  gravity,  and  taken  by  persons  in  permanent  con- 
tact with  the  patients,  be  considered  as  incomplete  manifesta- 
tions of  diphtheria,  or  in  other  words,  as  cases  of  diphtheria 
ivithout  diphtheria  {diplitheries  sans  dipJitJierie)!  I  find  no  diffi- 
culty in  entertaining  this  view.  Not  only  have  these  sore  throats 
followed  pseudo-membranous  sore  throat,  but  they  have  pre- 
ceded them  also.  Moreover,  in  admitting  this  form  of  diph- 
theria we  do  not  deviate  from  what  we  are  doing  with  regard  to 
other  diseases. 

Diphtheria  is,  therefore,  a  specific  and  contagious  general 
disease.  It  is  one  which  is  primarily  infectious  and  suscepti- 
ble of  exhibiting  the  most  varied  degrees  of  intensity.  This 
gradation  in  intensity  Professor  Lasegue  impliedly  recognized 


3/0  DIPirillEKIA,    CROUP    AND    TRACHEOTOMY. 

in  describing,  under  the  name  of  dipJitheroide,  a  species  of  sore 
throat  which  he  considered  as  a  degenerated  form  of  diphtheria. 
It  is  wholly  different  with  the  diphtheroide  as  Boussuge  un- 
derstood it.  Under  this  name  this  author  created  a  pseudo- 
diphtheritic  morbid  entity,  having  a  common  feature  with 
diphtheria,  viz.,  the  plastic  product,  but  of  absolutely  different 
nature.  He  made  it  up  of  elements  completely  heterogeneous, 
viz,  ulcero-membranous  stomatitis,  the  disease  described  by 
Chavanne  under  the  name  of  diphtheria  of  the  genitals  of  par- 
turient women,  an  affection  which  is  in  reality  only  a  gangrene, 
and  he  classed  here  also  the  asthenic  phagedenic  gangrene, 
observed  in  children  by  Caillault  and  Bouley,  and  even  hospi- 
tal gangrene  to  which  Robert  had  applied  the  improper  name 
of  dipJitliei'itis  of  %vounds. 

These  morbid  states  have  nothing  in  common  with  diphtheria; 
but  they  belong  to  the  gangrenous  process. 

From  the  showing  that  has  just  been  made  there  results: 
1st.  that  diphtheria  is  a  general  disease  from  the  first;  2d,  that 
it  is  one  and  specific,  since  it  includes  the  different  pseudo- 
membranous affections, whatever  be  their  site  and  their  intensi-^ 
ly  ;  and  these  affections  transmit  others  of  the  same  nature,  but 
which  often  differ  in  site  and  in  intensity.  If  we  add  that  it  is 
epidemic  and  contagious,  we  will  have  recognized  in  it  all  the 
features  of  general  specific  diseases.  Like  those  diseases  also, 
diphtheria  is  infectious.  It  impregnates  the  whole  economy.  It 
alters  the  blood  profoundly,  as  the  sepia  color  of  that  liquid, 
the  leucocytosis  and  the  haemophilia  prove  ;  while  the  passage 
of  that  vitiated  liquid  through  the  capillary  system  explains 
the  numerous  visceral  lesions. 

Its  infectious  nature  is  also  proved  by  the  gangrene,  the 
adenitis,  the  albuminuria  and  the  paralysis.  Infection  plays 
such  an  important  role  in  diphtheria,  and  the  patients  are  so 
profoundly  saturated  with  it  in  certain  cases,  that  they  maybe- 
come  the  foci  of.septicffimia  at  the  same  time  as  of  diphtheria 
proper,  and  transmit  the  first  to  those  to  whom  they  do  not 
communicate  the  second.  The  cases  of  Drs.  Pouquet,  Lareau, 
Baudry,  Wagner,  and  those  which  were   cited  by   Hiller,  show 


NATURE    OF    DIPHTHERIA.  371 

US  physicians  receiving  by  inoculation  the  blood  of  diphtheritic 
patients  and  presenting  in  consequence,  erysipelas,  and  septi- 
csemic  symptoms.  The  instance  of  Dr.  Pouquet  is  still  more 
complete  and  deserves  to  be  cited  in  full.  A  child  of  two  years 
was  attacked  with  a  diphtheritic  sore  throat  and  with  croup 
which  necessitated  tracheotomy.  It  succumbed.  Its  grand- 
mother, who  had  not  left  it,  contracted  a  severe  diphtheritic 
sore  throat  which,  however,  recovered.  Dr.  Pouquet,  who  per- 
formed the  tracheotomy,  wounded  his  finger  during  the  opera- 
tion. A  frightful  erysipelas  supervened  in  the  hand,  and  reached 
the  arm.  It  was  accompanied  by  the  most  formidable  symp- 
toms of  septicaemia,  and  placed  our  friend  in  danger  for  several 
days,  and  left  upon  his  system  a  characteristic  impress  which 
slowly  disappeared.  The  family  physician,  who  devoted  him- 
self entirely  to  the  patient,  with  whom  he  passed  long  hours, 
contracted  an  erysipelas  of  the  face,  from  which  he  had  the 
good  fortune  to  recover.  This  example  shows  what  power  the 
infectious  quality  of  diphtheria  may  attain. 

We  now  know  diphtheria  in  its  nature,  and  in  its  totality. 
Let  us  inquire  what  process  it  adopts  in  its  manifestations.. 
This  general  disease  usually  reveals  itself  by  localizations  upon 
the  mucous  membranes  and  upon  the  skin,  determinations 
whose  process  is  a  specific  inflammation  giving  rise  to  a  special 
product,  viz.,  the  false  membrane. 

At  the  time  when  Bretonneau  wrote  science  was  still  under 
the  rule  of  the  doctrines  of  Broussais.  Irritation  explained 
everything,  and  there  was  no  disease  which  was  not  an  inflam- 
mation. While  protesting  against  the  exclusiveness  of  that 
school,  and  demonstrating  that  inflammation  assumed  different 
and  specific  features  in  its  course  as  well  as  in  its  products, 
features  which  varied,  not  only  with  the  structure  of  the  tissues 
upon  which  it  manifested  its  action,  but  also  with  the  causes 
which  it  recognized,  while  bringing  these  profound  modifica- 
tions into  the  prevailing  doctrine,  Bretonneau  still  remained 
sufficiently  attached  thereto,  to  make  the  disease  which  he  de- 
scribed an  inflammation  and  a  specific  inflafnmatiou,  to  which 
he  gave  the  name  of  diphtheritis. 


1^2  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

A  more  extended  knowledge  of  the  disease  showed  that 
these  inflammatory  lesions  were  but  the  result  of  a  general, 
specific  and  infectious  disease,  like  the  pyrexias,  like  the  viru- 
lent affections  which,  impregnating  the  whole  economy,  man- 
ifest themselves  on  the  exterior  under  the  form  of  products  of 
an  inflammatory  nature.  Such  are  small-pox,  syphilis,  typhoid 
fever  and  the  like.  This  principle  having  prevailed,  the  name 
was  changed,  and  diphthoitis  became  diphtheria.  The  legiti- 
macy of  this  conclusion  is  self-evident,  for  it  results  from  all 
that  has  been  said  in  the  different  portions  of  this  work. 

Recognizing  diphtheria  as  a  general,  toxic  disease,  with 
what  diseases  should  it  be  classed  ?  Is  it,  properly  speaking, 
a  virulent  disease  or  one  of  those  pyrexias  which  seems  to  re- 
sult from  the  absorption  of  a  morbific  germ  by  the  respiratory 
passages?  It  should  be  placed,  according  to  my  notion,  with 
typhoid  fever,  and  especially  with  scarlatina  and  variola,  with 
which  it  offers  so  many  analogies.  Like  them,  it  appears  as 
benign  or  malignant,  discrete  or  confluent,  and,  as  with  them, 
the  morbid  poison  is  propagated  by  contagion. 

WHAT  IS  THE  NATURE  OF  THE  DIPHTHERITIC  POISON  ? 

The  present  state  of  science  does  not  permit  that  question 
to  be  answered.  The  tendency  which  comes  to  us  from  Ger- 
many, and  which  consists  in  giving  a  large  place  in  pathology 
to  the  parasitic  element,  could  not  fail  to  make  diphtheria  a 
zymotic  disease. 

Letzerich,  among  others,  has  described  a  fungus,  the  zygo- 
desmus  fitscns  which  he  thinks  the  specific  principle  of  diph- 
theria. I  have  shown  in  the  article  on  PatJiolcglcal  Anatomy 
that  this  parasite  has  no  special  relation  to  diphtheria,  any 
more  than  the  viicrococcns,  another  microphyte  to  which  Oertel, 
Eberth,  Nassiloff,  etc.,  attributed  the  same  properties. 

[In  reference  to  the  pathology  of  diphtheria,  Loffler  has  re- 
cently been  experimenting  with  reference  to  the  specific  path- 
ogenic micro-organisms  which  he  claims  stand  in  the  relation 
of  cause  and  effect  to  this  disease.  His  experiments  were 
divided  into  three  classes  : 

I.  Histological  examinations  of  the  tissues  of  patients    (ton- 


NATURE    OF    DIPHTHERIA.  373 

sils,  mucous  membrane  of  the  pharynx  and  larynx  and  inter- 
nal organs)  who  had  died  of  diphtheria. 

2.  Cultivation  of  two  species  of  bacteria  which  he  had  dis- 
covered during  those  examinations,  namely,  micrococci  in 
chains  and  a  bacillus. 

3.  Subcutaneous,  muscular,  corneal  or  tracheal  inoculation 
of  products  of  such  culture  from  the  fourth  to  the  twenty-fifth 
generation  upon  several  of  the  lower  animals  (mice,  guinea-pigs, 
rabbits,  pigeons.) 

Of  the  two  species  of  micro-organism  above  referred  to, 
the  micrococcus  seems  to  be  identical  with  those  observed 
and  studied  heretofore,  but,  his  experiments  led  him  to  the  fol- 
lowing conclusion,  that  "Since  the  chain  micrococci  excited  in 
no  animal  an  artificial  disease  even  resembling  diphtheria;  and 
since  they  were  only  observed  in  a  limited  number  of  cases  of 
human  diphtheria,  and  then  in  association  with  bacilli ;  and 
since  they  exactly  resemble  the  micrococci  of  erysipelas  and 
other  infectious  diseases,  they  are,  therefore,  only  accidental 
complications  of  diphtheria.  They  may,  however,  sometimes 
excite  a  disease  resembling  it,'" 

The  bacilli  were  then  isolated  and  cultivated  ;  the  result  of 
the  experiments  with  these  new  bacilli  is  stated  by  him  as  fol- 
lows :  They  were  found  in  thirteen  cases  of  diphtheria  with 
fibrinous  exudation  ;  they  lay  in  the  oldest  part  of  the  mem- 
brane and  penetrated  farther  toward  the  tisues  than  the  other 
bacteria ;  products  of  the  cultures  of  them,  carried  to  the 
twenty-fifth  generation,  when  inoculated  under  the  skin  of  the 
guinea  pigs  and  small  birds,  kill  the  animals,  after  the  produc- 
tion of  whitish  or  haemorrhagic  exudation  at  the  point  of  infec- 
tion and  extensive  subcutaneous  oedema.  The  inner  organs 
remain  intact,  as  do  those  of  the  diphtheritic  patients.  Pseudo- 
membranes  were  generated  by  inoculation  of  the  trachea  of 
rabbits,  chickens  and  pigeons  or  of  the  vagina  of  guinea  pigs. 
There  are  then  also  evidences  of  several  vascular  lesions,  man- 
ifested by  haemorrhagic  oedema,  by  haemorrhages  into  lym- 
phatic glands,  and  effusions  into  the  pleural  cavity.  The 
bacilli,  he  says,  have  thus  the  same  effects  on  the  animal  organ- 
ism as  the  diphtheritic  virus. 


374  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

This  bacillus  is  regarded  as  identical  with  that  described  by 
Klebs  as  the  one  pecular  to  diphtheria.  It  is  about  the  length 
of  the  tubercle  bacillus  but  double  its  breadth.  Its  modus 
operandi  is  supposed  to  be  the  development  of  a  poison  which 
causes  the  surrounding  tissues  to  decay  and  produces  paraly- 
sis of  the  blood-vessels,  thereby  causing  congestions  and  exu- 
dations, and  produces  paralysis  of  nerve-centres  and  death. 

Alas,  however,  Loffler  confesses  that  in  certain  well-marked 
cases  of  diphtheria  the  bacillus  was  absent.  N.  Y.  Med.  Rec- 
ord.  1885.] 


PROGNOSIS. 


This  question  has  been  treated  in  detail  thronghout  this 
work.  Each  form  and  each  localization,  as  well  as  the  compli- 
cations and  the  etiological  data,  have  been  appreciated  from 
the  point  of  view  of  the  restrictions  which  they  impose  upon 
the  prognosis.  By  referring  to  the  corresponding  chapters, 
the  influence  which  these  different  circumstances  exercise 
upon  the  "course  of  the  disease,  can  be  appreciated.  There 
should  be,  therefore,  no  necessity  for  taking  up  the  subject  in 
detail  again,  but  only  of  giving  a  general  summary  of  it. 

Taken  altogether,  diphtheria  is  a  severe  disease.  However 
benign  it  may  appear,  we  are  never  sure  that  a  sudden  change 
may  not  arise  and  transform  it  into  a  fatal  disease.  The  poison- 
ing may  go  on  quietly  and  undermine  the  building,  which  un- 
expectedly falls  to  pieces,  without  showing  a  single  positive 
symptom  which  could  enable  us  to  foresee  the  fatal  termina- 
tion. On  the  other  hand,  cases  which  seemed  desperate  are 
seen  to  end  in  a  return  to  health.  Nevertheless,  apparent 
gravity  for  the  time  being,  in  a  case  of  diphtheria,  always  varies 
according  to  numerous  circumstances.  Certain  of  the  causes 
which  affect  the  prognosis  remain  impenetrable  to  our  means 
of  investigation.  Why  is  one  epidemic  more  fatal  than  an- 
other which  has  preceded  it  in  the  same  region,  and  in  appar- 
ently similar  climatic  conditions?  We  answer  that  question 
by  the  somewhat  vague  expressions  of  constitution  medical  or 
oi genius  epidemicus,  which  only  reproduce  it  in  another  form 
and  thus  show  that  the  answer  is  yet  to  be  found. 

Beside  these  questions  which  remain  inappreciable,  there  are 
others  whose  domain  can  be  recognized.  Those  which  dom- 
inate all  the  others  are  the  form  of  the  disease  and  its  localiza- 
tion. 

The  infectious  or  the  malignant  form  is  always  grave,  what- 

(375) 


3/6  DH'HTHEKIA,    CROUP    AND    TRACHEOTOMY. 

ever  be  its  localization,  for  the  poisoning  kills  the  patient^ 
though  the  false  membranes  may  have  only  an  insignificant 
development  and  do  not  obstruct  the  functions  of  a  single  or- 
gan essential  to  life.  The  outlook  also  becomes  very  dark  when 
the  patient  presents  wholly  or  in  part  the  following  symptoms, 
viz.,  profound  alteration  of  the  features,  extreme  pallor,  pros- 
tration of  strength,  incessant  agitation  or  somnolence,  smallness 
and  slowing  of  the  pulse,  a  tendency  to  syncope,  general  or 
partial  coldness  of  the  body,  complete  anorexia,  considerable 
swelling  of  the  cervical  ganglia  with  oedematous  tumefaction 
of  the  cellular  tissue,  an  ichorous  and  fetid  discharge  from  the 
the  nose  and  mouth,  mortification  of  the  tissues,  brown  color 
of  the  false  membranes,  etc. 

A  limited  extent  of  the  false  membranes,  therefore,  is  not 
always  an  indication  of  benignity.  Yet,  apart  from  the  cases 
in  which  the  symptoms  just  cited  are  met  with,  a  discrete  false 
membrane  oftener  coincides  with  a  diphtheria  of  little  gravity. 
On  the  other  hand  generalization  of  the  exudate  is  the  most 
frequent  index  of  a  grave  condition.  It  is  the  rule  in  such 
cases,  while  a  limited  false  membrane  is  the  exception.  Its 
propagation  to  the  nose,  the  conjunctiva,  the  Eustachian  tube, 
the  genitals,  the  skin,  is  an  unpleasant  sign,  saying  nothing  of 
its  extension  to  the  larynx  and  to  the  bronchi  which  adds  to 
the  danger  of  infection,  that  of  asphyxia. 

Localization  of  the  disease  is  also  of  great  importance  in  the 
matter  of  prognosis.  However  superficial  the  infection  may 
be,  the  disease  becomes  fatal  from  the  time  when  it  compro- 
mises an  important  function.  Such  a  diphtheria,  when  local- 
ized in  the  pharynx,  on  the  conjunctiva,  in  the  mouth,  on  the 
genitals,  etc.,  would  have  promptly  got  well,  but  it  kills  the  pa- 
tient by  asphyxia  when  it  produces  an  exudate  on  the  surface 
of  the  larynx.  Still,  in  this  case,  art  is  all  powerful,  and  tra- 
cheotomy triumphs  almost  constantly,  if  some  complication 
does  not  intervene.  But  if  to  the  laryngeal  diphtheria,  that  of 
the  bronchi  is  added,  the  fatal  influence  of  the  localization 
again  preponderates.  We  add,  that  the  invasion  of  the  bronchi 
is  sufficient  to  exclude  a  case  of  diphtheria  from   the   category 


PROGNOSIS.  377 

of  benign  diphtheria,  for  such  extension  proceeds  from  in- 
fection. 

The  form  of  the  disease  and  its  localization  are,  therefore, 
the  two  principal  influences  which  govern  diphtheria. 

The  previous  health  is  still  another  source  of  very  inportant 
indications  for  prognosis.  Secondary  diphtheria  is  always 
grave,  for  it  almost  always  assumes  the  infectious  form  and 
sometimes  the  malignant  form.  Among  the  diseases  to  which 
diphtheria  succeeds,  certain  ones  exercise  a  more  pernicious 
influence  than  others ;  and  the  abstracts  which  I  have  given  in 
detail  have  enabled  me  to  show  that  these  diseases  should  be 
classed  as  regards  gravity,  in  the  following  order: 

hi  the  Jit  st  rank,  tuberculosis  and  typhoid  fever. 

In  the  secojid  rank,  pneumonia,  pleurisy,  small-pox,  urticaria 
and  the  various  cachexias,  snch  as  scrofula,  chronic  diarrhoea, 
syphilis,  etc. 

///  the  third  rank,  and  always  following  the  same  order,  mea- 
sles, scarlatina  and  whooping  cough. 

Among  the  diseases  which  may  precede  diphtheria,  we 
must  include  diphtheria  itself.  This  disease  in  fact  recurs.  It 
seems  that  if  diphtheria  does  not  prevent  a  new  invasion  it 
renders  it  at  least  less  severe.  In  29  cases  of  recurring  diph- 
theria 22  resulted  in  cure.  The  existence  of  a  previous  diph- 
theria, seems,  therefore,  favorable  as  to  prognosis. 

Age. — The  younger  the  patient  the  greater  the  peril ;  while 
its  maximum  corresponds  with  the  period  comprised  between 
birth  and  the  age  of  tw^o  or  three  years.  This  rule  is  verified 
in  the  vast  majority  of  cases.  The  proposition  should  not  be 
generalized  to  the  point  of  pretending  that  diphtheria  is  less 
grave  in  proportion  as  the  patient  advances  in  years.  It  is 
more  severe  in  the  adult  and  in  the  old  than  in  the  youth. 
Eminently  depressant  in  its  nature,  it  requires  of  the  patient  a 
power  of  resistance  and  considerable  vitality  to  enable  him  to 
recover.  These  considerations  explain  why  it  is  so  grave  at 
the  extremes  of  life  as  well  as  among  subjects  already  run 
down  by  cachectic  diseases. 

Sex. — Each  sex  has  in  its  own  turn  had  the   advantage  ac- 


3/8  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

cording  to  observers.  In  reality  this  circumstance  has  no 
more  influence  on  the  prognosis  than  upon  the  etiology.  We 
meet  with  series  more  favorable  to  one  or  to  the  other,  but 
just  as  I  have  shown  in  the  chapter  on  etiology,  it  should  be 
recognized  that  the  two  sexes  are  on  an  equality  as  regards 
diphtheria. 

Temperament,  hygiene,  social  status. — The  lymphatic  or  scrof- 
ulous temperament  is,  as  many  authors  aver,  of  unpleasant 
augury  in  diphtheria.  The  lowered  vitality  of  subjects  so  con- 
stituted explains  that  peculiarity.  It  also  follows  from  the 
tables  which  I  have  prepared  on  the  subject  of  secondary 
diphtheria, "that  the  mortality  among  the  scrofulous  is  consid- 
erable. Bad  hygienic  conditions,  those  which  are  oftenest  met 
with  among  the  poorer  classes,  have  also  their  influence. 
Want,  crowded  lodgings,  absence  of  care  and  of  nourishment, 
should  be  taken  into  serious  consideration.  Patients  lodged 
in  too  close  quarters  are  under  the  permanent  influence  of 
auto-infection.  The  necessity  of  a  nutritious  and  diversified 
alimentation  shows  how  much  the  chances  of  recovery  are  sub- 
jected to  a  bad  regimen. 

Seasons. — The  table  of  mortality  from  croup  at  St.  Eugenie 
shows  that  the  maximum  of  deaths  coincides  with  the  months 
of  March,  April  and  May,  whence  it  insensibly  diminishes 
to  attain  its  minimum  in  June,  September  and  October.  These 
results  correspond  with  those  which  pertain  to  etiology.  The 
greatest  gravity  of  the  cases  coincides  with  their 
greatest  freauency,  i.  e.,  with  the  cold,  wet  and  changeable 
seasons.  In  the  tables  prepared  by  E.  Besnier,  which  figured 
in  the  reports  of  the  Commission  on  prevailing  diseases,  and 
which  comprise  the  period  extending  from  1868  to  1880,  we 
see  that  the  entries  into  the  hospitals  and  the  number  of 
deaths  declined  to  their  minimum  in  June  in  September  and 
October.  Let  us  remember  that  these  statements  do  not  in- 
clude all  the  manifestations  of  diphtheria,  but  croup  only.  The 
following  table  is  prepared  from  the  documents.  [See  page  322] 

Complications. — The  pulmonary  inflammations  which  com- 
plicate  diphtheria   are    reckoned    among   the    most   powerful 


PROGNOSIS.  379 

causes  of  death.  They  carry  off  the  immense  majority  of  those 
cases  which,  by  reason  of  the  sHght  intensity  of  the  poisoning 
seemed  progressing  toward  recovery.  The  most  common, 
and  at  the  same  time  the  most  formidable,  is  broncho-pneu- 
monia ;  then  come  pneumonia  and  other  affections  which  are 
much  more  rare.  The  eruptive  fevers  also  find  numerous  vic- 
tims among  the  convalescents  from  diphtheria.  Measles  and 
scarlatina,  which  prevail  endemically  in  the  wards  of  the  hos- 
pital, include  most  of  them. 

Previous  treatment. — Patients  enfeebled  by  loss  of  blood,  by 
mercurials  or  by  alkalies,  depressed  by  emetics,  by  repeated 
vomiting,  by  the  terror  which  cauterization  inspires  and  by  the 
efforts  which  they  make  to  escape  it;  and  those  who  are  attacked 
by  diphtheria  of  the  skin  produced  by  vesicants ;  all  such  pa- 
tients find  themselves  placed  in  conditions  which  aggravate 
the  prognosis. 

Scquel(2. — The  invasion  of  diphtheritic  paralysis  may  be  of 
evil  augury.  Although  it  more  frequently  recovers,  it  some- 
times causes  death  by  its  generalization  and  by  its  extension 
to  respiratory  muscles  and  even  to  the  heart.  Then  the  risk  of 
asphyxia  from  the  passage  of  food  into  the  bronchi,  and  the 
possibility  of  inanition  are  among  the  accidents  which  should 
be  borne  in  mind  when  giving   a  prognosis. 

Independent  of  the  causes,  general  and  particular,  which 
make  diphtheria  a  grave  disease,  the  statistics  of  these  latter 
years  have  established  a  marked  aggravation  in  the  disease 
both  in  the  increase  in  number  of  patients  and  in  the  mortal- 
ity. The  following  table  taken  from  the  reports  of  the  com- 
mission on  prevailing  diseases  gives  the  statistics  of  croup 
alone  since  1866  (see  table,  p.  322). 

The  weekly  bulletins  of  the  causes  of  death  according  to  re- 
ports to  the  civil  government,  give  account  of  the  ravages 
which  diphtheria  produced  in  the  population  of  Paris,  reckoned 
according  to  the  census  of  1872  at  1,851,792  inhabitants  and 
1876  at  1,988,806.    [See  also  p.  383]. 


380  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

MORTALITY  OF  DIPHTHERIA  FOR  THE  CITY  OF  PARIS. 


Years 

Population. 

Deaths    from 
Diphtheria. 

Per  cent,  of  deaths 
front     diphtheria 

of  the  total  deaths 

in  the  1,000 

Per     cent,    of  the 
deaths  from  diph- 
theria of  the  'uhole 
population  in  the 
10,000. 

1872 

1,851,792 

39,650 

1,13s 

28.80 

6.17 

1873 

1,851,792 

41,752 

1,164 

27.83 

6.27 

1874 

1,851,792 

40,759 

1,008 

24.70 

531 

1875 

1,851,792 

45,544 

1,328 

29-15 

6.17 

1876 

1,988,806 

48,579 

1,572 

32-35 

7-94 

1877 

1,988,806 

47,509 

2,393 

50.36 

11.98 

1878 

1,988,806 

47,851 

1,989 

41.68 

10.00 

1879 

1,988,806 

51,095 

1,783 

34-89 

941 

1880 

1,988,806 

56,628 

2,033 

35-90 

I0.22 

419,347 

14,405 

34-35 

8.16 

A  considerable  aggravation  is  seen  to  coincide  with  the  year 
1875.  Far  from  diminishing,  this  tendency  has  only  increased. 
The  year  1876  proclaimed  itself  as  particularly  obnoxious  in 
this  respect. 

The  advance  is  considerable.  The  proportion  of  deaths 
from  diphtheria  which  was  one  in  5,763  inhabitants  during  the 
first  three  months  of  1875,  was  one  in  4,538  during  the  corres- 
ponding period  in  1876.  The  numbers  noted  in  the  hospitals 
in  Paris  tell  the  same  story  for  they  show  an  increase  in  num- 
ber and  in  gravity,  which  has  been  perceived  with  regard  to 
croup  also  during  1868  and  1880.  (See  p.  322). 

These  results  are  corroborated  by  the  statements  of  phy- 
sicians who  observed  diphtheria  in  the  hospitals  and  in  the  city. 
The    infectious    and  malignant  character  of  the  disease    was 


PROGNOSIS.  381 

more  and  more  marked,  and  not  only  did  the  recovery  of  those 
who  were  operated  on  by  tracheotomy  become  exceptional, 
but  the  fatality  of  diphtheria  limited  to  the  pharynx,  assumed 
unwonted  proportions.  Bergeron  reported  that  of  ten  patients 
in  whom  the  circumference  of  the  isthmus  and  the  posterior 
wall   of  the  pharynx  were  alone  invaded,  nine  succumbed. 


382 


DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

Mo  rta  liiy    Sta  t  is  tics . 


MORTALITY  STATISTICS  ABROAD. 


For   the    Year    1884. 

s 

5 

< 

1 

s 

I 

<3 

to 

•2 

2285 

"i 

3188 

985 

914 

•V. 

1 

4133 

5 

8 

London,  4,019,361, 

83,051 

21,379 

13,664 

1732 

1444 

20.6 

Liverpool,  573,202, 

14,691 

3,996 

83 

201 

621 

553 

206 

106 

844 

25.6 

Glasgow,  517,941, 

14,158 

3,143 

2,950 

291 

429 

378 

781 

245 

15 

563 

27.4 

Birmingham,  421,258, 

9,141 

2,612 

44 

128 

332 

291 

81 

63 

718 

21.7 

Dublin,  351,014, 

10,090 

2,151 

1,596 

121 

360 

23 

135 

"220 

— 

366 

28.S 

Manchester,  338,296, 

9,058 

2,274 

23 

223 

198 

206 

80 

7 

486 

26.8 

Leeds,  327,324, 

8,032 

2,104 

67 

487 

219 

165 

145 

I 

536 

24.6 

Sheffield,  300,563, 

6,871 

1,941 

17 

475 

21 

128 

91 

34 

530 

22.8 

Edinburgh,  246,703, 

4,925 

1,025 

895 

lOI 

71 

90 

272 

96 

— 

178 

19.9 

Bellast,  216,622, 

5,073 

913 

1,119 

36 

161 

9 

89 

83 

— 

234 

234 

Bristol,  215,457, 

4,024 

986 

18 

40 

50 

93 

47 

— 

150 

18.7 

Bradford,  209,564, 

4,286 

1,123 

8 

■hi 

103 

58 

55 

— 

261 

20.5 

Hull,  181,225, 

3,887 

1,174 

30 

44 

90 

62 

77 

17 

333 

21.4 

Newcastle,  151,325, 

3,552 

950 

14 

153 

16 

80 

58 

12 

160 

234 

Havre,  105,867, 

3>278 

839 

362 

104 

14 

2 

28 

51 

2 

442 

31.0 

Rheims,  93,823, 

2.808 

917 

277 

lOI 

7 

yi 

10 

70 

I 

701 

29.9 

Nancy,  74,954, 

1,864 

342 

166 

17 

8 

10 

3 

62 

I 

148 

22.2 

Breslau,  290,000, 

9,381 

3,278 

882 

234 

60 

208 

37 

96 

— 

1043 

31.8 

Brussels,  171,293, 

4,250 

998 

608 

106 

31 

26 

63 

59 

93 

639 

24.8 

Cologne,  150,513, 

4,061 

1,549 

341 

28 

6 

10 

106 

24 

13 

481 

26.2 

Christiana,  122,000, 

2,489 

686 

401 

124 

136 

96 

4 

— 

241 

20.4 

Frankfort,  145,100, 

3,040 

806 

312 

84 

25 

45 

61 

18 

— 

243 

20.7 

Hanover,  131,200, 

2,738 

832 

214 

71 

30 

25 

n 

36 

— 

225 

20.8 

PROGNOSIS. 
MORTALITY  STATISTICS  ABROAD— Continued. 


383 


For  the    Year  1884. 

5^ 

s 

S 

is  s 

<3 

<-> 

5i 

§ 

Bremen,  119,561, 

2,512 

844 

295 

50 

97 

2 

28 

10 

I 

145 

21.0 

Dantzic,  116,162, 

3.109 

1,111 

196 

111 

nz 

2 

35 

36 

2 

330 

27.4 

Stuttgart,  109,937, 

2,461 

936 

214 

112 

9 

30 

38 

27 

I 

271 

22.3 

Strasbourg,  110,739, 

2,907 

1,194 

564 

58 

6 

74 

31 

24 

— 

572 

26.2 

Dusseldorf,  105,287, 

2,741 

1,266 

222 

n 

19 

19 

50 

33 

— 

375 

25.6 

Nuremburg.  105,176, 

3,021 

1,101 

424 

79 

24 

227 

35 

25 

— 

448 

28.7 

Chemnitz,  102,713, 

3,414 

1,692 

107 

19' 

25 

10 

19 

24 

— 

64 

33-2 

Magdeburg,  105,000, 

2,822 

1,022 

215 

103 

37 

46 

55 

38 

— 

270 

25-9 

Elberfeld,  101,000, 

2,412 

682 

199 

84 

101 

31 

30 

31 

— 

156 

24-5 

Barmen,  100,000, 

2,260 

627 

170 

108 

37 

68 

22 

29 

— 

232 

22.6 

Altona,  97,000, 

2,590 

836 

248 

74 

47 

20 

48 

34 

— 

303 

26.7 

Aix-la-Chapelle,89,i  16 

2,549 

1,056 

271 

19 

— 

15 

82 

25 

— 

361 

28.6 

Mayence,  64,120, 

1,523 

432 

165 

26 

23 

71 

5 

26 

128 

23.8 

Amsterdam,  350,202, 

10,298 

667 

465 

237 

128 

66 

5 

76 

28.3 

Rotterdam,  166  001, 

4,527 

90 

118 

220 

40 

19 

I 

53 

27-3 

The  Hague,  131,417, 

3,354 

— 

100 

18 

73 

23 

16 

— 

60 

25-5 

Lyons,  376,613, 

9,415 



1,615 

104 

22 

86 

75 

147 

250 

626 

25.0 

Berlin,  1,225,065, 

33,205 

12,984 

1,897 

2667 

409 

298 

536 

418 

20 

5696 

27.1 

Hamburg,  486,678, 

12,753 

4,319 

1,201 

465 

127 

117 

188 

130 

— 

1316 

26.2 

Dresden,  236,000, 

6,199 

1,190 

444 

462 

88 

57 

140 

50 

1 

441 

26.3 

Munich,  240,000, 

7,469 

2,982 

710 

184 

69 

123 

^33 

40 

4 

1187 

3I-I 

Leipzig,  164,636, 

4,235 

1,654 

302 

399 

71 

79 

65 

37 

3 

429 

254 

Koenigsburg,  154,000, 

4,651 

1,854 

359 

250 

195 

I 

13 

67 

2 

602 

30.2 

Burcharest,  200,000, 

5,632 

2,772 

854 

200 

189 

99 

21 

120 

2 

532 

28.1 

Paris,  2,239,928, 

58,195 

9,5" 

5,342 

2147 

163 

1548 

450 

Jf54 

80 

5938 

26.0 

In 

iiarrhre 

al  disea 

ses  in  1 

'aris- 

-Che 

)Iera, 

943- 

384  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

MORTALITY  TABLE  FOR   1880,  ACCORDING    TO   U.   S-   CENSUS. 


States. 

1 

v! 

1 

•** 

s 
s 

i 

1 

t 

1 

United  States, 

8772 

16416 

38398 

1 1202  22905 

6556519155183670^107904 

34094 

Alabama, 

403 

25 

!  258 

58. 

783 

1417 

1729  1675 

2722 

665 

Arizona, 

3 

3 

10 

II 

15 

18 

19 

33 

16 

Arkansas, 

277 

295 

157 

446 

437 

1341 

955 

1424 

2852 

688 

California, 

33 

71 

370 

135 

:   298 

527 

1802 

1306 

1514 

567 

Colorado, 

70 

46 

249 

34 

78 

146 

210 

182 

556 

92 

Connnecticut, 

46 

"3 

216 

82 

196 

599 

1389 

I38I 

1225 

361 

Dakota, 

14 

16 

301 

7 

34 

70 

116 

105 

188 

51 

Delaware, 

7 

35 

82 

34 

76 

209 

357 

291 

286 

83 

District  of  Columbia, 

6 

42 

19 

88 

82 

570 

793 

515 

524 

219 

Florida, 

16 

5 

27 

50 

lOI 

216 

263 

358 

346 

180 

Georgia, 

526 

31 

594 

654 

993 

1954 

1718 

1879 

3066 

1327 

Idaho, 

2 

3 

55 

4 

12 

12 

22 

27 

46 

17 

Illinois, 

641 

1369 

2422 

504 

1653 

4630 

4655 

5146 

7400 

2100 

Indiana, 

524 

1319 

1037 

561 

1458 

2883 

3943 

3456 

4964 

1099 

Iowa, 

177 

609 

2326 

144 

723 

i860 

J925 

I93I 

2870 

856 

Kansas, 

521 

512 

1098, 

222 

663 

1801 

1117 

1306 

2566 

644 

Kentucky, 

273 

378 

394 

551 

816 

1952 

3733 

2612 

3415 

958 

Louisiana, 

128 

23 

187 

164 

302 

1227 

1514 

I76I 

2103 

867 

Maine, 

36 

286' 

1 

895 

56 

193 

433 

1829 

1136 

1045 

342 

Maryland, 

76 

5S3| 

623 

291 

475 

1754 

2381 

2062 

2040 

744 

Massachusetts, 

84 

80S 

1610 

290 

620 

2597 

5207 

3837 

4385 

I29*S 

Michigan, 

25s 

52S 

2002 

341 

547 

1463 

2613 

1902 

2432 

829 

Minnesota, 

93 

20 

1562 

84  318' 

1 

857 

848 

760 

990 

452" 

PROGNOSIS.  385 

MORTALITY  TABLE  FOR  188     ACCORDING  TO  U.  S.  CENSUS— Cont'd. 


States. 


Mississippi, 

Missouri, 

Montana, 

Nebraska, 

Nevada, 

New  Hampshire, 

New  Jersey, 

New  Mexico, 

New  York, 

North  Carolina, 

Ohio, 

Oregon, 

Pennsylvania, 

Rhode  Island, 

South  Carolina, 

Tennessee, 

Texas, 

Utah, 

Vermont, 

Virginia, 

Washington, 

West  Virginia, 

Wisconsin, 

Wyoming, 


1 

"Si 

1 
1 

=5 

147 

6 

212 

330 

332 

981 

770 

296 

885 

486 

1452 

4034 

I 

25 

26 

— 

8 

19 

152 

391 

1041 

41 

210 

522 

— 

18 

17 

II 

17 

46 

37 

138 

344 

15 

117 

314 

52 

567 

510 

99 

280 

X648 

•54 

119 

10 

178 

50 

60 

661 

1985 

4097 

748 

1260 

7207 

425 

"3 

lOII 

653 

966 

2063 

263 

1335 

2103 

502 

1376 

3715 

16 

47 

188 

28 

103 

159 

400 

2241 

5483 

470 

1660 

4666 

I 

540 

230 

28 

84 

317 

302 

18 

551 

459 

585 

1 280' 

147 

80 

779 

477 

952 

2033 

326 

90 

235 

600 

1087 

3403 

24 

25 

749 

17 

55 

121 

49 

65 

296 

41 

118 

269 

421 

268 

568 

419 

679 

2281 

II 

15 

III 

8 

15 

53 

112 

227 

513 

125 

232 

540 

91 

470 

1934 

133 

395 

1294 

2 

37 

18 

— 

3 

7 

'S' 


^ 


1287 

3604 

18 

416 

61 

866 

2630 

50 

1285S 

2130 

5912 

266 

8073 

691 

1543 

3767 

1622 

69 

813 

3025 

100 

969 

1681 

5 


1436 

4117 

28 

442 

55 

751 

2941 

72 

10129 

1792 

5738 
182 

8199 
575 

1450 

2368 

2450 

185 

608 

2569 

61 

742 

1698 

III 


2678 
6797 

44 
867 
I 

633 

2549 

295 

12715 

2599 

5045 

167 

8072 

5" 
1949 
3901 
3898 

457 

699 

3190 

96 

939 
2028 


•^ 


•^ 


746 

1636 

15 
240 

27 

241 

822 

131 

3959 

1027 

1974 
73 

2434 
158 
987 

1237 

1308 

71 

141 

1300 

31 
320 

757 
6 


The  mortality  rate  is  52.32  to  the  thousand  of  all  deaths  in   which   the  cause 
ported,  and  in  portions  of  the  Lake  S'ates  it  ran  as  high  as  84.10  per   thousand. 


IS  re- 


386 


DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 


MORTALITY    FROM    DIPHTHERIA    AND    CROUP   IN   THE    UNITED 
STATES  DURING   1883   AND    1884. 


1883. 

1884. 

City   and  Population. 

.« 

•S 

G 

Boston,  Mass.,  427,940, 

445 

163 

608 

345 

142 

487 

San  Francisco,  Cal.,  235,ock). 

102 

30 

132 

51 

24 

75 

Providence,  R.  I.,  120,000, 

54 

35 

89 

57 

32, 

90 

Albany,  N.  Y.,  99,495, 

64 

79 

143 

32 

43 

75 

Buffalo,  N.  Y., 

84 

39 

123 

75 

102 

177 

Minneapolis,  Minn.,  129,200.  (?) 

116 

116 

Brooklyn,  N.  Y.,  665,602, 

409 

318 

727 

385 

280 

665 

New  York,  N.  Y.,  1,397,895, 

1009 

644 

1653 

1090 

748 

1838 

Pittsburg,  Penn.,  180,000, 

170 

II 

181 

321 

4 

325 

Philadelphia,  Penn.,  927,995, 

1006 

500 

1506 

680 

589 

1269 

Cincinnati,  0.,  280,000, 

78 

62 

140 

71 

81 

152 

Cleveland,  O.,  200,429, 

247 

lOI 

348 

139 

57 

196 

Detroit,  Mich.,  140,00, 

293 

100 

393 

343 

104 

447 

Indianapolis,  Ind., 

16 

17 

iZ 

27 

15 

42 

Chicago,  111.,  630,000, 

592 

225 

817 

649 

256 

905 

Bloomington,  111., 

2 

5 

7 

I 

10 

II 

St.  Louis,  Mo.,  400,000, 

425 

116 

541 

553 

134 

687 

Salt  Lake  City,  Utah,  25,000 

II 

5 

16 

25 

8 

32, 

District  of  Columbia,  200,000, 

85 

24 

"3 

— 

— 

— 

NevF  Orleans,  La.,  234,000, 

67 

20 

87 

94 

61 

155 

Baltimore,  Md.,  408,520, 

591 

201 

792 

343 

127 

470 

TREATMENT. 


The  different  forms  of  diphtheria,  its  local  manifestations 
and  its  complications,  by  changing  the  aspect  of  the  disease, 
modify  the  conditions  to  which  the  treatment  should  be 
adapted.  Therapeutics  not  possessing  any  remedy  which 
can  justly  claim  to  be  a  specific  for  diphtheria,  the  treatment 
should  endeavor  to  fulfill  the  indications  which  appear  in  each 
case  in  particular.  Now,  these  indications  are  numerous. 
There  is  a  kind  of  non-complicated,  benign  diphtheria  which 
recovers  spontaneously  with  or  without  sequences  ;  another, 
implicating  important  organs,  or  dependent  upon  an  infectious 
form,  demands  treatment  the  most  assiduous  and  varied,  and 
even  requires  the  intervention  of  surgery. 

To  arrest  the  production  of  false  membranes,  to  destroy 
those  that  are  produced,  and  to  counteract  the  septicaemia  and 
its  depressing  influences ;  these  are  the  general  indications. 
Others  are  inferred  from  the  local  manifestations  also  of  the 
disease  ;  they  attempt  to  avert  the  functional  disturbances  re- 
sulting from  the  pseudo  membranous  exudation  in  the  larynx, 
in  the  nasal  fossse,  in  the  bronchi,  etc.  A  final  series  is  de- 
rived from  pulmonary,glandularand  other  complications,  as  well 
as  from  sequences,  such  as  paralysis  and  anaemia.  All  medica- 
tions, of  whatever  kind,  aim  at  meeting  these  indications.  To 
exhibit  them  in  an  order  which  enables  the  reader  to  find  them 
easily,  I  shall  place  each  of  them  in  relation  with  the  indica- 
tion which  is  to  be  fulfilled,  and  the  secondary  ones  will  be 
grouped  around  the  most  important.  They  comprehend 
three  principal  classes  : 

First  Class. — Genet'al  indications.  I.  To  destroy  the  false 
membranes;  II,  To  prevent  their  production;  III,  To  treat 
the  general  conditions. 

Second  Class, — Indications  fiiftiished  by  the  local  manifest 

(387) 


388  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

tations.  I.  Angina;  II.  Croup;  III.  Coryza ;  IV.  Pseudo- 
membranous bronchitis;  V.  Blepharo-conjunctivitis ;  VI. 
Diphtheritic  otitis;  VII.  Stomatitis;  VIII.  Cutaneous  diph- 
theria;  IX.   Diphtheria  of  the  genital  organs. 

Third  Class. — hidications  arising  from  complications  and 
sequences.  The  first  will  be  followed  organ  by  organ,  as  I  have 
done  in  giving  the  symptoms.  The  second  comprehends  diph- 
theritic paralyses. 

FIRST  CLASS. 

General  Indications. 

§  I .    To  Destroy  the  False  Membranes. 

For  a  long  time  all  the  efforts  of  therapentics  were  directed 
to  this  end.  The  promoters  of  this  method  were,  we  must 
acknowledge,  consistent  with  the  idea  which  they  had  formed 
of  diphtheria.  In  their  view,  the  false  membrane  was  the 
starting  point  of  the  disease;  the  infection  of  the  economy  was 
the  consequence  of  the  alteration  of  the  false  membrane  and 
of  the  absorption  of  the  products  of  this  alteration.  Thus,  we 
have  seen  Bretonneau,  Trousseau  and  many  others  follow  up 
the  false  membrane,  caustic  in  hand,  without  stopping  either 
for  the  pain  or  the  struggles  with  the  patients,  without  fearing 
the  frequently  terrible  accidents  which  followed  it  as 
a  consequence.  They  believed  themselves  bound  to  apply 
these  means  with  "  une  sauvage  energie,"  in  the  words  of 
Trousseau.  Now  that  it  is  fully  demonstrated  that  the  false 
membrane  is  the  product  and  not  the  cause  of  the  intoxica- 
tion, we  understand  that  to  suppress  the  false  membrane  is  not 
to  cure  the  disease.  As  fast  as  one  causes  the  concretion  to 
disappear,  it  is  replaced  by  another  so  long  as  the  tendency  of 
the  system  to  produce  the  false  membrane  persists.  In  follow- 
ing this  course  one  undertakes  a  task  perpetually  returning, 
useless  and  even  dangerous  !  This  principle,  however,  admits 
of  exceptions.  When  the  abundance  and  rapid  thickening  of 
the  false  membranes  become  a  cause  of  embarrassment,  when 
their  rapid  alteration    makes  them   a  source   of  infection,    we 


TREATMENT.  389^ 

should  seek  to  modify  them.  Their  situation  upon  an  essential 
organ,  of  which  they  compromise  the  action,  for  example,  the 
larynx,  is  still  a  powerful  motive  for  removing  them.  It  is, 
therefore,  especially  in  view  of  such  cases,  that  it  is  well  to  be 
armed  with  local  modifiers.  This  might  be  the  place  to  notice 
the  substances  and  the  processes  which  have  been  made  use 
of  with  this  object,  but  to  avoid  repetition  I  prefer  to  reserve 
their  examination  for  the  time  when  I  shall  be  occupied  with 
the  treatment  of  the  local  manifestations,  and  especially  ot 
angina,  against  which  and  that  of  all  the  local  determinations 
all  the  artillery  of  therapeutics  has  been  brought  to  bear. 

§  2,     To  Prevent  the  Production  of  the  False  Membranes. 

Three  orders  of  means  have  been  brought  into  requisition 
to  this  end.  The  first  are  directed  against  the  specific  inflam- 
mation which  produces  the  false  membrane;  they  are  the  an- 
tiphlogistics.  The  second  make  the  pretension  of  diminishing 
the  supposed  excess  of  the  plasticity  of  the  blood,  which  was 
claimed  to  be  the  cause  of  the  fibrinous  exudation  ;  these  are 
the  alteratives.  The  third,  without  affixing  any  theoretical  ex- 
planation, claim  to  act  as  specifics. 

A. — Antiphlogistics. 
ist.  Sanguineous  Emissions. 

When  all  diseases  were  subjected  to  this  treatment,  diph- 
theria did  not  escape.  It  appeared  that  these  means,  alone  or 
combined  with  local  treatment,  should  be  correct  lor  inflam- 
mation, supposed  to  be  purely  local,  which  produced  the  false 
membranes.  Moreover,  it  follows  from  the  reading  of  early 
observations,  that  the  inflammatory  element  appeared  to  haye 
a  sufficiently  important  part  in  diphtheria,  which  it  has  now 
lost  in  large  measure,  to  the  gain  of  the  infectious  element.  In 
spite  of  these  considerations,  the  confidence  at  first  placed  in 
these  means  should  be  withdrawn  from  them.  Still  more,  they 
have  been  finally  regarded  as  injurious.  This  result  was  antic- 
ipated.     In  a  disease  as  an^miating  and   debilitating  as  diph- 


390  UIFJIJ-HEKIA,    CKOUP    AND    TKACIIICOTO.MY. 

theria,  sanguineous  emissions  even  limited,  as  those  resulting 
from  the  application  of  leeches  in  the  regions  of  the  diseased 
parts,  only  increase  this  primordial  disposition  which  is  so  un- 
favorable. The  age  of  the  patients,  which  is  nearly  always 
infancy,  a  period  when  spoliation  is  ill-supported,  furnish  an  ad- 
ditional centra-indication.  Another  serious  inconvenience  de- 
serves to  be  noticed  ;  the  bites  of  the  leeches  may  become 
themselves  the  starting  points  of  cutaneous  diphtheria.  There- 
fore, of  no  profit,  of  serious  inconveniences,  the  general  aban- 
donment of  the  system  is  sufficiently  evident. 

2.  Revulsives. — One  may  offer  to  these  the  same  objections. 
In  fact  they  are  either  insignificant,  like  the  rubefacients,  or 
they  are  quite  dangerous,  being  entirely  without  beneficial  ef- 
fect, like  the  blisters.  We  know  that  these  latter  seldom  fail 
to  become  covered  with  false  membranes  ;  they  aggravate  the 
condition  of  the  patient,  and  when  placed  on  the  front  of  the 
neck,  in  the  vain  hope  of  combatting  croup,  they  constitute 
one  of  the  most  serious  difficulties  in  the  way  of  tracheotomy. 
[I  have  seen  this  more  than  once]. 

J.  Emetics. — Employed  especially  in  view  of  a  mechanical 
action,  they  possess,  however,  a  real  antiphlogistic  action 
which  may  be  profitably  combined  with  the  first.  But  the  lat- 
ter being  much  the  more  efficacious,  I  shall  occupy  myself  with 
the  details  of  emetics  at  the  same  time  as  with  the  means  which 
act  mechanically  upon  the  false  membrane. 

B. — Alteratives. 

The  tendency  of  the  economy  to  transude  fibrin  has  favored 
the  supposition  of  an  excess  of  fibrin  in  the  blood.  Hence, 
the  emplo}'ment  of  alterative  remedies,  contra-stimulants,  and 
defibrinating  means. 

This  practice  was  ingenious  and  plausible,  but  it  was  defect- 
ive in  foundation.  Nothing  is  less  proved  than  this  excess  of 
fibrin.  The  blood  of  the  diphtheritic  is  poor  in  fibrin  as  well 
as  in  globules.  The  fact  is  shown  by  the  tendency  to  haemor- 
rhages, by  the  feeble  coagulability  of  the  liquid  blood,  by  the 
fluid  appearance  in  which  we  found  it  in  the   cadaver,  without 


TREATMENT.  39 1 

speaking  of  the  more  advanced  alterations  such  as  sepia  blood. 
Everything  in  diphtheria  shows  a  tendency  to  what  has  been 
called  the  dissolution  of  the  blood,  the  dyscrasia.  It  is,  there- 
fore, not  a  case  for  the  administration  of  medicines  which  ag- 
gravate this  condition.  This  error  having  been  generally  rec- 
ognized, the  alterative  medication  has  received  a  blow  from 
which  it  will  with  difficulty  recover.  The  detailed  exposition 
of  this  treatment  will  show  still  better  its  inconveniences. 

The  therapeutic  agents  recommended  with  this  view  are 
the   mercurials,   the   alkalies   and   the   antimonials. 

I'sX  Mercurials. — They  have  been  employed  internally  in  the 
form  of  calomel;  externally  in  the  form  of  mercurial  inunctions. 

Calomel. — The  important  position  in  therapeutics  given  to 
this  remedy  by  English  and  American  physicians,  should  pre- 
serve for  it  a  favorable  place  in  the  treatment  of  diphtheria. 
Besides,  it  has  been  given  in  every  form,  and  in  all  doses, 
Thomas  Bond,  of  Philadelphia,  seems  to  have  been  the  initia- 
tor of  this  treatment  in  America.  Samuel  Bard  gave  it  in  from 
0.20  to  0.30(3  to  5  grs.)adayin  combination  with  one-sixteenth 
as  much  opium  to  modify  its  purgative  action.  Rush  increased 
the  dose  to  0.60  or  1.20  (10  to  18  grs.)  a  day.  Physic  went  as  far 
as  2  grammes  (30  grains)  in  children  less  than  a  year  old.  The 
English  physicians,  among  whom  we  should  mention  Dobson, 
Cheyne,  and  Hamilton,  gave  of  it  from  0.05  to  o.  10  gr.  (Y^  to 
1V2  g^s.)  every  hour  to  children  of  one  year,  and  0.15  (2Y4  grs.) 
to  those  of  two  years,  and  so  on,  until  the  respiration  was  less 
embarrassed.  Then  diminishing,  they  left  an  interval  between 
the  doses  of  two,  three  or  four  hours,  according  to  the  indica- 
tions. Others  administered  broken  doses  according  to  the 
method  of  Law.  The  German  physicians  have  dispensed  this 
remedy  with  the  same  liberality.  Autenrieth  gave  0.07  (a 
grain)  for  each  year  of  the  child's  age  up  to  i.oo  to  1.25(15 
or  20  grains),  always  prescribing  a  vinegar  enema  in  order 
to  exert  upon  the  intestine  an  energetic  derivation.  In  France 
a  much  greater  reserve  has  been  shown.  Bretonneau  recom- 
mended to  give  every  hour  .20  (3  grains),  and  at  the  same 
time  to  apply  mercurial  inunctions  every  three    hours.     While 


392  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

liquefying  the  blood, they  hoped  that  the  calomel  would  modify 
the  false  membranes  in  passing,  at  the  same  time  that  by  its 
specific  action  upon  the  mucous  membrane  of  the  throat  and 
of  the  mouth  it  would  facilitate  the  separation  of  the  exudates, 
and  obstruct  their  reproduction.  If  these  hopes  had  been  jus- 
tified this  remedy  could  have  been  counted  as  a  veritable  anti- 
diphtheritic  ;  but  they  have  ever  remained  in  the  condition  of 
promises.  Several  authors  who  have  used  this  mercurial  salt 
report  recoveries.  But  we  know  how  difficult  it  is  to  appre- 
ciate exactly  the  action  of  a  therapeutic  agent,  to  estimate  the 
influence  that  it  has  had  upon  the  termination  of  a  disease. 

It  has  given  but  little  more  success  than  other  methods,  and 
its  use  is  founded  upon  an  erroneous  theory.  Moreover,  it  is 
far  from  being  innocent ;  it  often  occasions  serious  symptoms 
which  have  been  decidedly  to  the  disadvantage  of  that  which 
was  really  our  object.  All  authors  have  reported  excessive 
salivation,  mercurial  stomatitis  with  extensive  ulcerations, 
loosening  of  the  teeth,  gangrene  of  the  mouth,  obstinate  diar- 
rhoea, and  free  haemorrhages.  Often  it  is  the  cause  of  a  real 
cachexia  of  which  the  least  danger  is  to  prolong  remarkably 
convalescence.  These  accidents  have  also  attracted  the  atten- 
tion of  Prof  Barbosa,  of  Lisbon. 

Different  means  have  been  employed  to  avoid  these  incon- 
veniences. Miquel,  of  Amboise,  had  the  ingenious  idea  of 
combining  alum  with  the  calomel.  He  gave  alternately  every 
two  hours  gm.  o.oi  (Ye  gr.)  of  calomel,  and  gm.  0.15  (274  grs.) 
of  alum  in  powder.  The  astringent  action  of  the  alum  pre- 
vented the  stomatitis,  the  diarrhoea  and  the  haemorrhages. 
Aside  from  some  disappointments  which  the  author  candidly 
states,  this  method  has  always  been  one  of  perfect  harmless- 
ness,  and  it  has  removed  in  large  part  the  dangers  inherent  to 
the  mercurial  preparations ;  Barthez  has  verified  the  advan- 
tages of  it  in  this  respect ;  even  recognizing  this  point  we 
may,  notwithstanding,  entertain  doubts  of  the  efficacy  of  this 
remedy. 

Mercurial  Inunctions. — They  act  at  once  as  a  cutaneous  local 
remedy  and  by   absorption,  and   one    may    object    that   their 


TREATMIiNT.  "  393 

action  is  doubly  injurious.  The  mercury  absorbed  gives  rise 
to  all  the  symptoms  above  cited  ;  its  contact  with  the  skin  ex- 
cites mercurial  eruptions  which  often  ulcerate  and  become  cov- 
ered with  diphtheria.  This  mode  of  treatment  should,  there- 
fore, be  proscribed  absolutely,  in  spite  of  the  opinions  of  Step- 
puhn,  Behrens  and  of  Bartels  of  Kiel.  The  latter  recommends 
inunction  with  large  doses,  i.OO  (15  grs.)  an  hour,  and  although 
his  patients  recovered,  several  attained  this  end  only  after  a 
very  long  time,  in  spite  of  mercurial  symptoms  of  all  kinds. 

In  conclusion,  in  spite  of  hypothetical  advantages,  the  mer- 
curial treatment  presents  serious  inconveniences  which  are  real. 
The  only  form  in  which  it  may  not  be  dangerous  is  that  which 
Miquel  has  recommended.     All  others  should  be  rejected. 

2nd.  Alkalies. — Based  upon  the  same  theoretical  idea,  the 
alkaline  treatment  was  advocated  in  the  beginning  by  Moure- 
mans.  Of  this  class  the  bicarbonate  of  soda  was  the  most 
employed. 

Mouremans  prescribed  the  following  : 

Aqux  lactucae  120.  (Siv.)Bicarbonate  of  soda  2.50  (grs.xxxvi). 
Syrup  of  mulberry  or  blackberry  30.  (Si.)  Dose,  a  table- 
spoonful  every  two  hours. 

Baron  in  1839  and  then  in  1856  recommended  the  eau  de 
Vichy  and  bicarbonate  of  soda.  He  prescribed  one  or  two 
bottles  a  day  and  from  i.  to  2.  (15  to  30  grs.)  of  the  salt.  In 
1853,  Dr.  Lemaire  published  some  observations  to  demonstrate 
the  good  effects  of  the  bicarbonate  of  soda  in  the  treatment  of 
diphtheria.  But,  as  in  these  cases  the  salt  of  Vichy  was  not 
given  alone,  it  is  difficult  to  decide  upon  its  efficacy.  Dr. 
Laignez  sustained  the  ideas  of  his  teacher  Baron.  From  read- 
ing the  observations  contained  in  the  memoirs  of  these  two 
authors,  it  is  found  that  Baron  had  to  deal  with  a  mild  form  of 
diphtheria,  or  perhaps  with  simple  herpetic  angina,  and  that 
several  of  the  patients  of  Laignez  were  attacked  with  benign 
scarlatinous  angina. 

Marchal,  of  Calvi,  also  supported  the  alkaline  method.  He 
gave  the  bicarbonate  of  soda  in  the  dose  of  i.  (15  grs.)  every 
hour,  that  is   12.  (3  drachms)  a  day.       But  he   did  not  furnish 


394  DIPHTHERIA,  CROUP  AND  TRACHEOTOMY. 

sufficient  proof  in  favor  of  this  method,  and  only  reported  a 
single  observation;  besides,  it  was  a  case  of  scarlatinous  angina 
which  he  treated  by  bleeding  at  the  same  time  as  with  the 
bicarbonate  of  soda.  The  medicine  ought  to  be  given  from  the 
commencement  of  the  disease.  Given  too  late  or  in  insufficient 
doses,  the  alkalies  are  without  effect.  This  treatment  presents 
the  same  inconveniences  as  the  mercurial,  though  in  a  less  de- 
gree. If  it  does  not  produce  symptoms  on  the  part  of  the 
mouth,  it  does  entail,  in  the  end,  a  bad  general  condition, 
well  known  as  the  alkaline  cachexia.  Baron  foresaw  the  ob- 
jection ;  he  preferred  to  reserve  this  means  for  sanguine  sub- 
jects, and  interdicted  it  in  cases  in  which  adynamia  prevailed, 
or  in  which  there  was  a  disposition  to  haemorrhage.  We  may 
say,  however,  in  defense  of  this  medication,  that  the  action  of 
bicarbonate  of  soda  is  slow  and  that  the  evolution  of  diph- 
theria, however  slow  it  may  be,  is  rarely  sufficiently  so  to  wait 
till  the  alkaline  medication  has  had  time  to  produce  its  anti- 
plastic  effect.  In  England  they  employ  quite  commonly  the 
following  remedy  recommended  by  Volquarts : 

For  children.  Adults. 


Of  I  year.  Of  6  yrs. 

Nitrate  of  soda. 

Bicarbonate  of  soda  aa,         i.  25(20grs.)  3.0  (45  grs.         8.-12.   (23-3  3) 

Gum,  4.  (i  3.)  8.  (2  3.)  15-  (4  3.) 

Distilled  water,  90.  (3  g.)  120.  (4  §.)  800.  (24  §.) 

Dose,  a  teaspoonful  (for  a  child)  or  a  tablespoonful  for  an  adult  every  hour. 
In  Germany  Kiichenmeister  prescribed  the  following: 
Carbonate  of  potash. 
Nitrate  of  potash  aa,        -         -  -  -  3   (45  grs.) 

Syup 30-  (I  §•) 

Water 120.  (4  §.) 

Dose,  a  tablespoonful  every  hour. 

Both  these  authors  accompany  the  use  of  these  draughts 
with  an  alkaline  gargle  of  which  I  shall  give  the  formula  here- 
after. 

Dr.  Kiihn  administers  carbonate  of  potash  internally  in 
doses  of  from  i. — 4.  (15  grs.)  to  6.(1 72  5)  according  to  the  age; 
and  habitually  combines  it  with  aqua   calcis.     I    intentionally 


TREATMENT.  395 

omit  to  speak  here  of  chlorate  of  potash,  the  real  action  of 
which  is  purely  local.  The  changes  of  the  false  membrane 
will  be  spoken  of  at  the  same  time.  The  sub-carbonate  of  Ain- 
ino7iia,  recommended  by  Rechou  (1804)  was  also  given.  But 
this  medicine,  difficult  to  administer,  has  long  since  been 
abandoned. 

In  conclusion,  the  alkalies  have  but  a  doubtful  efficacy. 
From  the  admissions  even  of  those  who  have  most  highly 
recommended  them,  we  should  fear  their  depressing  and 
liquefacient  action. 

3d. — Taj'trate  of  Antimony. — Long  since  this  salt  was 
used  in  large  doses  in  the  treatment  of  diphtheria.  From  a 
passage  taken  from  the  memoirs  of  Jurine  on  croup,  we  learn 
that  Bordeu  had  recourse  to  this  treatment  in  the  year  1744. 
Since  that  time  this  emetic  has  been  prescribed  by  Laennec, 
Delens,  Prus,  Chantourelle,  Mianowsky,  Foster,  Graves,  Bazin, 
Fabre,  Marotte,  Gigon  of  Angouleme,  Chapelle,  Baizeau,  Kor 
turn,Constantin,  of  Coutres,  Bouchut,  Beclere,  Zorgo  and  Nonat. 
The  emetic  effect  was  not  the  one  expected  of  this  treatment, 
it  was  supposed  to  act  directly  upon  the  diphtheritic  poison- 
ing. 

Gigon  said:  "  With  an  emetic  dose  one  combats  but  a  single  symptom,  the  ob- 
struction of  the  larynx,  while  the  tartar  emetic  in  a  large  dose,  liquefying  this  par 
excellence,  combats  the  morbid  diathesis  under  the  influence  of  which  the  albumin  of 
the  blood  concretes  and  passes  to  the  condition  of  a  membrane.  In  this  manner  the 
medicine  attacks  the  essence,  the  specificity  even,  of  the  diphtheria." 

Such  was  the  theory  which  inspired  the  promoters  of  this 
method. 

Bouchut  adopted  the  following  formula : 

Syrup  of  gum  acacia  100.  (§iij.) 
Syrup  of  poppies,  15.  (§ss.) 

Tartar  emetic,  0.50-75  (grs.  vij-xij.)  M.  Dose,  half  a  tablespoonful  every 
hour. 

Constantin    gave  the  following  formula: 

Syrup  of  gum  acacia,  250.  (§vijss). 

Syrup  of  morphine,  60.  (5ij.) 

Tartar  emetic,  I.  (grs.  xv.)    I\I.    Dose,  same  as  above. 

This  physician  did  not  fear  to  give  to  children  from  3  to  4 
years  old  as  much  as  9.  (2  drachms  and  a  quarter)  in  three   or 


3    6  DlPIITilERIA,    CROUP  AND    TRACHEOTOMY. 

four  days.  To  credit  several  of  these  observers,  this  emetic 
administered  in  this  way,  produced  no  inconveniences,  espec- 
ially by  taking  the  precaution,  as  recommended  by  Bouchut, 
of  giving  little  drink  to  the  patients,  and  making  them  take 
nourishment  in  the  form  of  thick  porridge.  The  same  author 
says,  "Tartar  emetic  is  employed  in  this  case  as  in  acute 
pneumonia,  and,  saving  in  exceptions,  it  does  not  produce  de- 
bility nor  distressing  prostration."  It  has  not  always  been  so 
with  other  physicians. 

Chappelle,  of  Angouleme,  in  1852,  after  having  extolled  the 
effects  of  tartar  emetic  in  large  doses  in  the  treatment  of 
croup,  sent  in  1859  to  the  Academy  of  Medicine,  a  second 
memoir  in  which  he  declared  that  he  had  to  abandon  this  treat- 
ment in  consequence  of  the  numerous  reverses  which  had  fol- 
lowed the  successes  of  the  beginning.  The  facts  observed  by 
Garnier  in  the  service  of  Barthez  and  published  in  his  thesis 
are  not  such  as  to  encourage  this  method. 

Given  in  doses  of  0.20  (3  grs.)  this  emetic  produced  vomit- 
ing, diarrhoea  and  prostration.  Of  six  (6)  patients,  two  (2)  died 
suddenly  after  the  disappearance  of  the  laryngeal  symptoms. 
In  another  the  first  spoonful  of  a  draught  of  .60?  (9  grs.)  pro- 
voked such  a  diarrhoea  that  it  was  necessary  to  suspend  its 
use. 

Fisher  and  Bricheteau  reported  that  in  six  children  observed 
by  them, and  who  were  submitted  to  this  emetic  draught,  three 
took  it  during  two  days,  and  experienced  in  consequence  ex- 
cessive vomitings  and  numerous  stools  ;  asphyxia  made  no  less 
progress,  and  tracheotomy  had  to  be  practiced.  In  two  oth- 
ers, the  first  spoonful  of  the  solution  produced  a  diarrhoea  so 
violent,  with  prostration  and  pallor  of  the  face,  that  they  were 
forced  to  abandon  it.  Finally,  the  last  died  suddenly  after 
having  taken  this  tartar  emetic  draught  during  twenty-four 
hours.  It  is  quite  interesting  to  note  these  three  sudden  deaths 
in  twelve  cases.  While  this  termination  may  be  well  known 
in  the  history  of  diphtheria;  it  is  presented  with  the  facts  which 
I  have  just  cited  with  a  frequency  which  is  due,  perhaps,  only 
to  a  mere  coincidence,  but  which  is  well  calculated    to    inspire 


TREATMENT,  397 

serious  reflections.  Barthez  long  since  abandoned  this  treat- 
ment which  he  saw  too  often  produce  a  cholera  or  diarrhoea, 
obstinate  vomiting  and  alarming  prostration.  These  symp- 
toms are  so  much  the  more  to  be  dreaded  in  proportion  as  the 
children  are  younger.  Tender  age  should  be  an  absolute  con- 
tra indication  [true].  Moreover,  in  reading  the  observations 
offered  in  support  of  this  mode  of  treatment,  we  see  that,  in 
the  majority  of  the  cases,  it  produced  every  day  and  several 
times  a  day  abundant  emesis.  Also,  the  majority  of  the  au- 
thors who  have  recommended  it,  insist  upon  the  necessity  of 
provoking  vomiting.  Their  statistics  show  that  the  recoveries 
have  been  obtained  from  among  the  patients  who  have  vom- 
ited. It  is  then  not  to  the  contra-stimulant  action,  but 
simply  to  the  emetic  effect  that  the  recoveries  may  be  at- 
tributed ;  just  as  well  give  the  medicine  in  emetic  doses,  it  is 
more  sure  in  effect,  and  less  dangerous. 

In  conclusion,  the  treatment  by  tartar  emetic  in  large  doses, 
involves  precautions  of  the  strictest  character  ;  and,  in  spite  of 
all  the  recoveries  placed  to  its  credit,  recoveries  which  often 
have  been  due  to  the  emetic  action  or  perhaps  to  other  means 
employed  concurrently,  as  certain  observations  prove,  in  spite 
of  these  successes,  we  are  bound  to  charge  to  its  account  not 
only  failures,  but  grave  symptoms  ;  namely,  choleriform  diar- 
rhoea, uncontrollable  vomiting,  prostration  and  perhaps  sudden 
death.  We  should  by  all  means  avoid,  in  young  children, 
these  fatal  effects  which  increase  in  inverse  proportion  with  the 
age.  Its  employment,  derived  from  a  false  theoretical  concep- 
tion, should  be  rejected.  It  is  not  sufficient  from  one  fortui- 
tous success  that  therapeutics  be  authorized  to  use  dangerous 
and  depressing  means.     [Hive  syrup  is  the  same  thing]. 

C. — Specifics. 

/.  Sulphuret  of  Potassium — liver  of  sulphur.  Proposed  for  the 
first  time  by  the  author  of  one  of  the  memoirs  for  the  great 
prize  in  1 808,  this  remedy  was  extolled  as  a  certain  specific, 
afterwards  it  fell  into  almost  complete  discredit.  It  is 
one    of  the    remedies  most  frequently    employed    at    Geneva, 


39^  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

and  appears  to  have  rendered  good  service  to  the  physicians 
of  that  city.  Maunoir  prescribed  it  in  doses  of  0.60 — 0.90  (9  to 
13  grs.)  in  twenty-four  hours,  in  an  emulsion.  Senf  advocated 
its  use  in  children  from  i  to  2  years,  in  doses  from  0.05 — 0.07 
(V*  ^o  I  fe^-);  to  those  older  from  o.  10 — 0.20  (i  to  3  grs.)  every 
two  hours,  dissolved  in  water  and  mixed  with  syrup.  One  can 
also  give  it  in  pills,  incorporating  it  with  the  extract  of  liquor- 
ice. This  dose  appears  too  large  to  Rilliet,  who  preferred  to 
administer  only  0.05 — o.io  (Yi  to  172)  every  two  hours  so  as  to 
give  from  0.50— i. 00  [y^j^  to  15  grs.)  in  the  twenty-four  hours, 
either  in  powder  or  in  emulsion.  It  is  given  most  frequently 
at  Geneva  in  the  form  of  a  syrup  composed,  according  to 
Chaussier,  of  the  following  formula:  Mix  0.80  (12  grs.)  of 
sulphuret  of  potassium  with  30.  (i  oz.)  of  simple  syrup.  Give 
every  two  hours  a  tablespoonful  of  the  mixture.  Klaproth 
made  also  a  syrup  of  it  which  differed  in  no  essential  manner 
from  the  former.  Dr.  Bienfait,  of  Rheims  has  again  brought 
forward  this  remedy.  A  comparison  which  he  made  in  the 
treatment  of  two  series  of  patients  has  decided  him  in  favor 
of  the  efficacy  of  the  liver  of  sulphur.  In  the  first,  sixteen  pa- 
tients were  treated  by  emetics,  cauterization,  mercurials,  etc., 
and  one  only  recovered.  In  the  second,  he  obtained  three  re- 
coveries in  six  cases  by  giving  the  sulphuret  of  potassium  in  doses 
of  0.15  (2Y2  grs.)  in  an  emulsion  of  120.00  (4  oz).  Notwith- 
standing these  recoveries,  the  liver  of  sulphur  has  appeared  to 
many  authors  as  a  dangerous  remedy.  Its  smell  and  taste  are 
very  disagreeable,  and  render  it  difficult  to  administer ;  it 
whitens  the  inside  of  the  mouth,  and  occasions  a  burning  sen- 
sation at  the  pit  of  the  stomach.  Several  physicians,  Bour- 
geois and  Chailly  among  others,  have  seen  it  frequently  pro- 
duce vomiting  as  well  as  colic,  and  a  choleriform  diarrhoea. 
Barthez  frequently  gave  it,  but  abandoned  it  because  of  the 
diarrhoea  it  produced,  and  because  of  its  failures.  It  is  neces- 
sary, therefore,  to  be  very  guarded  in  the  use  of  this  remedy, 
and  one  should  avoid  prescribing  it  for  young  children  who  are 
very  liable  to  have  diarrhoea. 

2.  Bromine.      Ozanam   first  advocated  the  use  of  bromine 


TREATMENT.  399 

and  its  compounds  in  the  treatment  of  diphtheria.  He  at- 
tributed to  the  metalloid  itself,  a  disaggregating  property,  and 
to  the  bromide  of  potassium  a  property  at  once  liquefying  and 
disaggregating.  Bromine,  accordingly,  would  be  the  specific 
of  the  pseudo-membranous  affections,  namely,  angina,  croup 
and  aphthae  [sic).  This  pretension  of  a  remedy  to  a  specific 
action  in  diseases  as  unlike  as  diphtheria  and  aphthae  should 
be  sufficient  to  shake  the  theory  of  the  author.  But  to  infer, 
from  the  solvent  power  which  a  medicinal  agent  possesses 
upon  the  morbid  products,  a  specific  action  upon  the  disease 
which  gives  rise  to  these  products,  is  to  run  into  mere  theory.  At 
that  rate  diphtheria  would  count  numerous  specific  remedies. 
Aqua  calcis,  lactic  acid  of  which  the  solvent  power  is  infinitely 
superior  to  that  of  bromine,  would  be  antidotes  much  more 
powerful  than  it.  According  to  the  same  author,  the  specific 
action  of  bromine  should  also  follow  from  the  fact  that  this 
substance  when  inhaled  into  the  air-passages,  determines  the 
formation  of  false  membranes  in  the  throat.  But  we  can  say 
as  much  also  of  ammonia ;  this  gas  has  been  employed  by  sev- 
eral observers  to  produce  artificially  false  membranes  in  the 
pharynx  and  larynx.  What  resources  should  we  not  have 
then  against  diphtheria,  if  these  views  should  enter  into  the 
domain  of  reality !  Unfortunately  our  means  are  much  more 
limited;  the  specific  of  diphtheria  is  yet  to  be  found.  If  bro- 
mine possesses  an  action  on  diphtheria,  it  is  one  of  an  entirely 
different  nature.  The  labors  of  Gubler,  Voisin,  Martin, 
Damonetteand  Pelvet,  etc.  have  demonstrated  that  bromine  and 
its  compounds  are  eliminated  by  the  salivary  glands,  by  the 
buccal  mucous  membrane  and  that  of  the  air-passages.  We 
can  then  see  in  this  metalloid  a  modifier  of  these  mucous  mem- 
branes ;  moreover,  the  false  membranes  being  in  constant  con- 
tact with  a  substance  which  exercises  upon  them  a  certain 
chemical  action,  may  be  profitably  modified.  The  effects  of  the 
bromine  may  be  analogous  to  those  of  the  chlorate  of  potas- 
sium. Reduced  to  these  terms  the  therapeutic  action  of  bro- 
mine is,  theoretically,  acceptable.  Are  the  facts  cited  by 
Ozanam  convincing  examples  of  this  action  ?    I  should   hardly 


400  DIPHTHERIA,    CROUP  AND    TRACHEOTOMY. 

admit  it.  Indeed,  bromine  is  eliminated  especially  by  the 
urine,  and  it  does  not  pass  in  a  perceptible  manner  into  the 
saliva,  only  when  given  in  quite  large  doses.  Now,  Ozanam 
took  for  the  basis  of  his  formulae  the  brominated  water  or  an 
aqueous  solution  of  bromine,  one  to  a  thousand  or  one  to  five 
hundred  ('/looo  or  Vsoo)-      He  formed  a  solution  of  it  as  follows  : 

Brominated  water,  v-xx  gtt. 

Distilled  water,  150.  (572  o). 

Simple  syrup,  30.  (i  §).  M.  Take  a  tablespoonful  from  hour 
to  hour. 

Under  certain  circumstances  this  physician  added  to  this 
formula  0.05  (V*  gr.)  of  bromide  of  potash.  The  infinitesimal 
quantity  of  bromine  which  enters  into  this  preparation  can 
have,  in  being  eliminated,  but  an  illusory  action  upon  the  false 
membranes.  By  raising  the  doses  the  conditions  become  such 
as  to  obtain,  from  this  remedy,  the  effect  which  its  physiolog- 
ical action  promises.  In  several  cases  of  diphtheritic  angina 
with  coryza  and  albuminuria,  I  have  made  use  of  the  bromine 
medication  internally  and  externally.  The  results  have  ap- 
peared satisfactory.  The  following  is  my  manner  of  proced- 
ure : 

1st.  Irrigation  in  the  nose  and  in  the  throat  with  the  bromi- 
nated water,  i  to  500. 

2.  Give  every  hour  a  tablespoonful  of  the  following  solution: 

]^      Aq.  destillatae,  125.  (4  5; 
Bromini  pur.,  6  gtt. 
Potassii  bromidi,  2. 50  (7  grs). 
Syrup,  30  (i  5).     M. 
This  treatment  has  always  been  well  borne.     In  this   form 
the  bromine  remedy  is  of  rational    application,   and   may   act 
upon  the  diphtheritic  manifestations  in  the  same  way  conceded 
to  analogous  medications,  that  is  to  say,  not  as  a  specific,    but 
as  a  topical  remedy.      Dr.    Schiitz,   like    Ozanam.    has   recom- 
mended the  treatment  by  bromine.    Dr.  Clemens  combines  the 
bromide  of  potassium  and  the  aqua    chlorinii.     He  prescribes 
a  solution  of  the  bromide  of  potassium    as  follows: 
Potassii  bromidi,  2. — 4.  (Vi-I  5). 
Aq.  destill.  80— IGQ.  (272-3  5). 


TREATMENT.  40 I 

Syrup,  simpl.  20.-30.  (5-73.)  M.  Dose,  a  tablespoonful  ever>' 
hour,  with  a  teaspoonful  of  aq.  chlorinii. 

[My  friend  Dr.  A.  K.  Van  Home,  of  Jerseyville,  111.,  has  great  confidence  in  the 
effects  q{  bromine  in  ihe  treatment  of  diphtheria.  The  following  is  the  formula  and 
method  of  administering: 

Bromide  of  potash  (a  saturated  aqueous  solution)  48.  (1V2SO 

Bromine  32.  (i  g.)  M.  Dose,  eight  drops  every  one,  two  01  three  hours,  ac- 
cording to  the  urgency  of  the  case,  given  in  cream. 

The  above  mixture  should  be  kept  in  a  ground-stoppered  bottle,  and  carefully  pro- 
tected from  the  light  by  colored  glass  or  colored  wrapping  paper. 

Dr.  Mollereau,  of  Paris,  lately  also  recommends  the  use  of  bromine  in  watery  solu- 
tion, I  %.  In  severe  cases  of  the  laryngeal  form,  he  gives  three  drops  of  the  solution 
in  a  teaspoonful  of  water  every  fifteen  minutes.  In  cases  not  so  severe  he  gives  the 
same  amount  less  frequently.  He  says  avoid  milk  and  farinaceous  articles  duiing  its 
use.     Dr.  W.  H.Thompson,  of  New  York,  stil  favors  the  bromine  treatment]. 

3d.  Iodine. — Employed  especially  as  a  topical  application 
and  as  an  antiseptic,  iodine  has  also  been  given  internally,  par- 
ticularly by  Forget.  Dr.  Hamilton,  of  Edinburgh,  speaks  of 
two  brothers  attacked  with  diphtheria  to  which  he  gave  the 
iodide  of  potash.  The  use  of  the  remedy  having  been  sus- 
pended, the  disease  became  worse ;  from  the  time  of  resuming 
the  treatment  it  declined  steadily  to  recovery.  More  numer- 
ous facts  would  be  necessary  in  order  to  judge  of  the  value  of 

[Dr.  Edward  Adamson  (Practitioner  ;  also  Jour.  Am.  Med.  Assoc.  Oct.  3,  1885) 
speaks  in  the  highest  terms  of  the  reliability  of  iodine  (tincture).  Only  two  cases 
died  out  of  fifty-five,  and  in  no  case  were  there  any  troublesome  sequelae.  Dose, 
from  5  to  7  minims  every  hour  or  two  hours,  according  to  the  cii  cumstances.  For 
children,  give  2  or  3  minims  every  two  hours  in  orange  syrup  or  some  other  neutral 
syrup.] 

4th.  TJie  Balsams. — Dr.  Trideau,  relying  upon  the  proper 
ties  possessed  by  copaiba  and  cubebs  of  being  eliminated  by  the 
air-passages,  believed  he  had  found  in  these  remedies  specifics 
which  would  favor  the  detachment  of  the  false  membranes  of 
the  larynx.  He  claims  to  have  employed  this  method  with 
success  in  more  than  three  hundred  cases.  The  disease 
yielded  at  the  end  of  three  or  four  days  ;  it  resisted,  at  the 
most,  one  week.  These  remedies  are  given  in  the  form  of  a 
syrup.     The  following  is  the  formula : 


402  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

Syrup  of  Copaiba. 

^     Copaibae  balsami  ...  -  -  go.  (2V2  g.) 

Pulv.  gum.  acacise  -  -  -  -  -  20.  (5  3  ) 

Tinct.  (essentise)  menth.  pip.    -  -  -  -  12  gtt. 

Tinct.  opii  ------  2  gtt. 

Syrup.  Simpl. 400.  (12  §.)     M. 

Syrup  of  Ctibebs, 

1^     Pulv.  cubebse      -  -  -  -  -  -         12.  (3  3-) 

Syrup,    simpl. 240.  (7V2  §.)  M. 

Give  every  other  hour  a  tablespoonful  of  the  syrup  of  copaiba  alternating  with  the 
same  dose  of  syrup  of  cubebs. 

This  remedy  had  a  great  notoriety  ;  it  is  still  employed  by 
a  number  of  physicians. 

It  has,  however,  undergone  some  modifications.  The  cubebs 
are  generally  used  alone  ;  the  copaiba  has,  really,  on  the  in- 
testinal mucous  membrane,  an  irritant  effect  which  it  is  nec- 
essary to  avoid,  the  alimentation  taking  rank  before  all  medi- 
cation. The  pharmaceutical  form,  the  most  agreeable  for  the 
use  of  cubebs  and  that  which  I  habitually  employ,  is  the  oleo- 
resinous  extract  which  has  the  great  advantage  of  containing 
in  a  small  volume,  the  active  principle  of  a  large  quantity  of 
the  powdered  cubebs;  if  the  patient  is  old  enough,  and  if  de- 
glutition is  not  too  painful  it  is  expedient  to  use  this  extract  en- 
closed in  soft  capsules.  Each  capsule  contains  0.50  (7'/.  min- 
ims), a  quantity  which  equals  nearly  7.5  (2  5)  of  the  powder.  We 
give  daily  three  or  four  or  even  six  of  these  capsules,  accord- 
ing to  age.  But  when  the  patient  is  quite  young,  and  when 
the  difficulty  of  swallowing  or  any  other  cause  prevents  giving 
non-triturated  substances,  we  must  give  the  oleo-resin  in  the 
form  of  an  emulsion  of  gum  or  otherwise.    I  use  the  following : 

Syrup  acaciae  (with  some  aromatic)   120.  (4  §) 

Oleo-resinae  cubebse,  0.50 — 2.0  (from  7  minims  to  ^^  5)    M. 

Dose,  a  tablespoonful  every  two  hours,  as  far  as  possible  at 
the  time  of  eating.  Cubeba  is  given  also  in  the  form  of  a  sac- 
charated  extract  (saccharure)  in  the  dose  of  20.  (5  5)  a  day. 

Bergeron  gives  it  ordinarily  in  this  form,  except  in  the  cases 
in  which  the  capsules  can  be  employed  for  cubebs.  This  mode 
of  treatment  has  against  it  the  very   disagreeable   taste   of  the 


TREATMENT.  ^03 

medicine.  This  is  of  little  importance  in  adult  persons,  who 
can  overcome  certain  repugnancies  by  appeal  to  their  judg- 
ment, but  it  becomes  a  real  objection  in  the  case  of  young 
children.  I  have  often  seen  the  patients  oppose,  resist  and 
finally  absolutely  refuse  the  medicine.  That  is  a  circumstance 
we  should  always  suspect  when  we  have  to  do  with  substances 
repugnant  to  the  taste.  It  is  to  be  feared  that  this  has  not 
been  sufficiently  considered  in  the  multitude  of  observations  in 
which  the  brilliant  successes  obtained  by  the  balsams  are  ex- 
tolled. Is  the  curative  effect  of  the  system  sufficiently  proved 
for  us  to  pass  on  ? 

And  first,  to  consider  diphtheria  as  a  pure  "specific  catarrhal 
affection  of  the  laryngeal  and  pharyngeal  mucous  membranes 
with  adynamic  tendencies,"  is  perhaps  to  simplify  the  question 
too  much.  From  this  view,  the  treatment  by  the  balsams  be- 
comes rational ;  but  is  it  correct  that  diphtheria  should  be  so 
understood  ?  We  can  answer  very  pointedly  in  the  negative. 
The  fibrinous  exudate  of  diphtheria  is  no  more  catarrhal  than 
that  of  pneumonia  is  fibrinous.  The  lesions  made  upon  the 
mucous  membranes  of  the  pharynx,  the  larynx  and  the  bron- 
chial tubes  by  the  first,  and  those  of  the  alveoli  and 
pulmonary  vesicles  of  the  second  are  similar.  The  two  diseases 
are  not  less  absolutely  distinct,  although  the  Germans,  too 
much  influenced  by  the  similarity  of  the  lesions,  have  applied 
to  this  form  of  pneumonia  the  qualification  croupal.  Has  any- 
one, even  by  making  this  confusion,  attempted  to  treat  pneu- 
monia by  the  balsams  ?  I  think  not.  Diphtheria  is  no  more 
amenable  to  this  treatment  than  pneumonia.  Theory  is,  there- 
fore, not  favorable  to  the  balsamic  treatment.  Is  the  practice 
in  opposition  to  the  theory?  The  excessive  proportion' ot  re- 
coveries attributed  to  this  method  seems  calculated  to  create 
suspicion  from  the  first.  An  action  so  constant,  and  an  agree- 
ment so  perfect  between  the  physiological  action  of  the  reme- 
dy and  its  therapeutic  effect  are  not  things  commonly  met 
with.  These  observations,  too  briefly  given  by  the  honorable 
promoter  of  this  treatment,  are  not  calculated  to  dissipate  these 
apprehensions.       Did  they  concern  true  diphtheritic  angina  or 


404  DIPHTIIKRIA,    CROUP    AND    TRACHEOTOMY. 

fully  confirmed  croup?  We  may  well  doubt  it,  and  so  much 
the  more  as  the  successes  appear  to  have  been  more  brilliant 
in  cases  of  primary  croup,  while  they  were  negative  (nothing) 
in  cases  of  croup  consecutive  to  membranous  angina,  that  is, 
in  the  only  case  in  which  the  diagnosis  might  be   indisputable. 

This  method  has  been  tried  on  a  large  scale  in  the  hospitals 
of  Paris  ;  as  in  all  the  therapeutic  systems  it  has  given  recov- 
eries, but  upon  these  fortunate  series,  reported  by  Bergeron, 
Archambault,  Moreau,  Vaslin  and  Courcelle,  have  followed 
reverses  no  less  numerous  which  have  shaken  greatly  the  early 
confidence  of  many  physicians. 

The  objections  which  this  treatment  suggests  have  been 
formulated  with  talent  by  Lavergne  and  Bastion.  So  far  as  I 
am  concerned,  I  may  add,  although  I  have  employed  this  treat- 
ment in  a  large  number  of  cases,  I  have  never  observed  from  it 
any  well  established  action.  This  is  also  the  opinion  of  Bar- 
thez. 

Finally,  the  efficiency  of  the  balsams  is  not  sufficiently  dem- 
onstrated to  give  us  the  right  to  impose  these  remedies  to  the 
diso-ust  of  patients.  Besides,  their  use  is  not  without  incon- 
venience. They  very  frequently  excite  purgative  effects  which 
it  is  absolutely  necessary  to  avoid. 

5th.  Expectorants. — With  an  idea  similar  to  that  of  Trideau 
several  authors  have  endeavored  to  modify  the  secretions  of 
the  affected  mucous  membranes.  Only,  in  place  of  endeavor- 
ing to  arrest  them  by  the  use  of  the  balsams,  they  have  de- 
voted themselves  to  the  purpose  of  augmenting  and  maturing 
them  by  prescribing  expectorants. 

Polygala  Senega. — Introduced  into  the  therapeutics  of  croup 
in  1 79 1,  by  Archer,  this  remedy  was  extolled  as  very  powerful 
by  John  Archer,  son  of  the  former.  This  medicine  was  pre- 
pared in  the  form  of  a  decoction  of  15.  (V'2  S)  of  the  bruised 
root  of  senega  in  250.  (8  S)  of  well  water,  boiled  down  to  125. 
4  oj).  Dose,  a  tablespoonful  every  hour  or  every  half  hour, 
according  to  the  severity  of  the  disease.  In  some  cases  he 
prescribed  the  powdered  senega  in  doses  of  from  0.20-0.25  (3-4 
grs.)  in  a  little  water.      Numerous  recoveries  were  obtained  by 


TREATMENT.  4O5 

this  remedy.  But  of  all  these  virtues  only  one  has  been  pre- 
served to  senega,  and  that  is  its  expectorant  power  which  may 
be  utilized  in  the  bronchitis  which  accompanies  diphtheria. 
This  plant  is  then  given  in  infusion,  in  the  dose  of  8.  (2.5)  in 
100.  (3  3)  of  water.  In  larger  doses  it  frequently  produces 
vomiting. 

The  Kcnnes  mineral  (antimonii  sulphuretum  prsecipitatum) 
has  been  employed  in  the  dose  of  .10 — .20  (I'y. — 3  grs.),  espe- 
cially by  Herpin,  of  Geneva.  Its  action  is  the  same  as  that  of 
senega.  This  remedy  has,  moreover,  the  inconvenience  of 
often  causing  very  distressing  nausea,  and  provoking  diar- 
rhoea, reasons  which  should  positively  contra-indicate  it  in  the 
treatment  of  diphtheria,  for  reasons  heretofore  indicated. 

In  the  same  list  with  these  remedies  we  may  place  jaborandi, 
an  agent  recently  introduced  into  therapeuties,  and  which 
has  not  been,  so  far  as  I  knew,  applied  yet  to  the  treatment  of 
diphtheria.  I  have  not  tried  it,  but  it  seems  that  the  decided 
secretory  activity  which  it  excites,  not  only  in  the  salivary 
glands  but  in  the  respiratory  mucous  membrane,  and  real  per- 
spiration of  the  trachea,  might  have  a  certain  action  upon  the 
false  membranes  and  facilitate  their  separation.  In  these  cases 
we  might  administer  it  to  children  in  the  dose  of  I.  (15  grs.) 
in  decoction  in  a  teacupful  of  water. 

[Recent  statements  of  the  treatment  of  diphtheria. 

Dr.  N.  Lunin,  of  St.  Petersburg,  has  given  the  results  in  the 
treatment  of  296  cases  of  diphtheria  occurring  in  the  Children's 
Hospital  of  the  Princess  of  Oldenburg. 

Their  constitution  and  condition  are  thus  stated :  25  only 
were  badly  nourished,  while  225  of  the  296  were  well  devel- 
oped and  well  nourished. 

The  tabulated  results  are  as  follows : 


4^6 


nirilTIlEKlA,  CKOL'P    AND    TRACIIKOTOMV. 


Fibrinous  /• 

orm. 

Phlcgmonous- 

-Septic 

Total. 

Form. 

•^ 

' 

i 

•^ 

Method  of  Treat- 

•S 

■:2 

f^ 

<; 

'a 

ment. 

« 

•^ 

,^ 

^ 

"i: 

-.** 

t3 

8 

^ 

•^ 

?i 

Ni 

^ 

•2 

N, 

C^ 

$ 

^ 

13 

^ 

^ 

^ 

^ 

^ 

Sublimate,    .     . 

43 

30.2 

14 

13 

92.9 

57 

26 

45-6 

Iron     .... 

43 

14 

32.6 

51 

39 

76.5 

94 

53 

56.3 

Chinolin .     .    . 

'9 

6 

31.6 

9 

9 

1 00.0 

28 

15 

53-0 

Resoicin  .     .     . 

lO 

2 

20.0 

19 

17 

89-5 

29 

19 

65-5 

Bromine  .     .     . 

15 

7 

46.7 

18 

16 

889 

33 

23 

69.7 

Turpentine  .     . 

12 

I 

8.3 

II 

9 

81.8 

23 

10 

43.4 

Total     .... 

142 

43 

30-3 

122 

103 

84.4 

264 

146 

55-3 

Fifty-seven  cases  were  treated  with  the  corrosive  subhmate. 
The  throat  was  pencilled  every  two  hours  with  a  i  per  cent  so- 
lution, and  washed  with  a  solution  of  i  to  5,000.  Wine  and 
musk  were  also  given. 

Ninety-four  cases  were  treated  with  tincture  chloride  of  iron 
of  which  from  i  to  8  cubic  centimeters  were  given  daily — not 
enough.  The  throat  was  gargled  every  two  hours  with  a  solu- 
tion of  boracic  acid,  and  stimulants  were  given. 

The  chinoline  was  applied  in  5  per  cent  solution  with  a  pen- 
cil and  a  wash  of  i  to  1,000  was  also  applied. 

Rosorcin,  it  will  be  seen,  had  little  effect  and  bromine  used 
in  '/i  to  72  per  cent,  solution  was  used  as  a  local  application 
every  three  hours,  and  in  solution  (.6  to  i.oo  per  300)  was  in- 
haled from  every  half  hour  to  every  two  hours. 

Oil  of  turpentine  was  given  in  twenty-three  cases  internally,  in 
gradually  increasing  doses  up  to  ten  drops  hourly  or  240  drops 
per  day.  The  stomach  was  not  disturbed  thereby.  A  gargle  of 
boracic  acid  was  used  ;  wine  and  musk  administered.  This 
seems  to  have  been  the  most  efficient  treatment  for  the 
fibrous,  and  iron  for  the  phlegmonous-septic  form.  Med.  Rec- 
ord.    July  18,  1885.] 


treatment.  4^7 

§  3. — General  Treatment. 

The  false  membrane,  although  it  is  the  most  palpable  symp- 
tom of  diphtheria,  is  still  but  one  part,  sometimes  the  least  im- 
portant of  the  morbid  totality  which  the  physician  is  to  com- 
bat. Two  principal  conditions  prevail :  septicaemia  and  ady- 
namia. However  variable  may  be  these  two  elements  of  the 
disease,  as  to  their  intensity,  they  always  exist  in  a  manner 
more  or  less  apparent.  The  general  treatment  of  diphtheria, 
therefore,  comprehends  the  antiseptic  and  the  restorative  treat- 
ment. 

The  authors  who  consider  diphtheria  as  a  zymotic  disease 
have  also  tried  an  antiparasitic  treatment.  But,  as  nothing  is 
less  demonstrated  than  this  ontological  view,  and  as,  on  the 
other  hand,  the  parasite  is  in  this  theory  only  the  agent  of 
the  septicaemia,  the  antiparasitic  and  the  antiseptic  treat- 
ment answer  one  and  the  same  indication  and  should  be  united. 
Hence,  I  comprise  them  both  under  the  name  of  antiseptic 
treatment. 

A. — Antiseptic  Treatment. 

The  entire  catalogue  of  disinfectant  remedies  has  been  em- 
ployed against  diphtheria. 

Among  these  therapeutic  agents,  one  of  the  most  vaunted 
was  the  perchloridc  of  iron.  Recommended  at  first  as  a  local 
application  by  Hatin,  Gigot,  of  Levroux,  and  by  Jodin,  who 
regarded  it  as  a  parasiticide,  this  remedy  became,  under  the 
influence  of  Aubrun,  an  antiseptic  of  energetic  effect  against 
diphtheria.  In  1S67,  Dr.  Aubrun,  Jr.,  gave  this  subject  an  im- 
portant place  in  his  inaugural  thesis.  The  following  is  the 
modits  faciendi  3i6i0^i&6.  by  this  author:  The  perchloride  of 
iron  is  to  be  given  dissolved  in  a  little  water.  If  the  child  re- 
jects it  a  little  simple  syrup  may  be  added.  Gummy  solutions 
should  be  avoided ;  they  form  with  the  ferric  salt  a  thick 
magma  which  is  difficult  to  swallow.  The  solution  should  be 
given  in  a  glass  or  in  a  porcelain  cup,  and  not  in  a  spoon,  the 
metal  of  which  would  decompose  the  ferric  salt.  The  patient 
should  abstain,  while  using  this  remedy,  from  drinks  or  food 
capable  of  altering  it,  such  as   wine,    and  in  general,    all  sub- 


408  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

stances  containing  tannin.  The  dose  is  from  4!  to  7.  (i  to  2  5) 
a  day.  It  is  given  in  divided  doses  of  from  20  to  40  drops 
which  is  mixed  in  a  glass  of  cold  water.  Every  five  or  ten 
minutes,  while  awake,  and  even  during  sleep,  we  give  a  mouth- 
ful of  this  solution.  Immediately  after,  the  patient  should 
drink  a  little  cold  milk  without  sugar,  or  soup.  According  to 
age,  the  patient  can  take  during  the  day  from  three  to  five  glasses 
of  this  solution  which  brings  the  quantity  to  about  the  amount 
above  given.  Authors  recommend  to  continue  the  remedy 
with  scrupulous  regularity  during  several  consecutive  days, 
even  during  the  first  three  nights.  That  would  be,  in  fact, 
towards  the  end  of  the  third  day  when  the  false  membranes 
would  become  softened  and  detached.  After  recovery  it  is 
necessary  to  take  the  precaution  to  continue  the  perchloride 
still  for  some  time  in  order  to  to  avoid  second  attacks.  As  to 
alimentation  it  should,  during  the  two  or  three  earliest  days,  be 
composed  exclusively  of  milk  or  soup  (bouillon).  Isnard,  of 
Saint-Amand-les-Eaux,  has  reached  the  same  conclusion. 
Courty,  of  Montpellier,  has  also  obtained  favorable  results.  He 
employs  intenially  and  externally  the  following  preparation  : 
Tincture  of  chloride  of  iron,  30  to  50  drops  in  a  glass  of  water. 
Dr.  Colson  declares  that  in  America  all  the  physicians  reject 
cauterization  and  employ  especially  the  perchloride  of  iron, 
chlorate  of  potash,  and  ice  internally  and  externally.  Heslop 
and  Houghton  prescribed  the  following  solution : 

^.     Aqus  240.  (772  S-) 

Tinct.  ferri  chloridi,  12.  (3  3-) 

Acid,  muriatici  dil.  8.  (2  5.)  M.  To  betaken  during  twen- 
ty-four hours. 

Dr.  Clarhas  employed  with  success  ferrated  glycerine  in  a 
score  of  cases,  half  of  which  were  grave.  His  formula  was  the 
following : 

Glycerine  60.  (2§.) 

Tincture  ferri  chloridi  gtt.  15, — 20.  Dose,  a  teaspooful  every 
half  hour. 

Dr.  Schobacher  speaks  highly  of  the  use  of  perchloride  of 
iron,  as  does  also  Prof.  Steiner. 


TREATMENT.  4O9 

Aside  from  the  antiseptic  action  which  does  not  appear  to 
me  demonstrated,  we  must  recognize  that  the  tonic  and  the 
coagulant  properties  of  this  remedy  would  have  a  favorable  ef- 
fect in  a  disease  which  produces  anaemia  and  dyscrasia.  These 
properties  very  probably  have  had  their  part  in  the  success  re- 
ported by  authors.  But  one  is  exposed  to  frequent  disappoint- 
ments by  expecting  the  action  of  this  remedy  to  be  otherwise, 
and  in  hoping  to  find  often  series  of  cases  equally  fortunate.  After 
having  enjoyed  great  favor  the  perchloride  of  iron  has  lost  ground 
like  all  agents  which  have  claimed  to  have  a  direct  action  upon 
diphtheria — of  being  its  antidotes.  In  comparing  the  results 
obtained  in  a  large  number  of  patients,  I  have  proved  that  the 
perchloride  of  iron  w^as,  in  general,  well  borne,  though  it  was 
not  always  so  easily  taken  as  Aubrun  thought,  but  I  have 
never  been  able  to  find  in  it  a  clearly  proved  action  upon  the 
disease.  However  that  may  be,  this  treatment  has  decided 
merits ;  it  answers  one  of  the  principal  indications  of  diph- 
theria ;  moreover,  it  is  without  disadvantages.  In  the  same 
list  with  the  perchloride  of  iron  one  may  place  gallic  acid, 
extolled  by  Dr.Sebastin  in  1866,  in  doses  of  from  i.to  2.(15 — 30 
grs.)  a  day. 

The  Labarraque's  solution  (Liq.  sodse  chlorinatae)  has  been 
prescribed  in  doses  from   i.  to  4.  (7*  to  i  5)  a  day. 

The  pcruiaiiganate  of  potash  is  also  used,  but  this  salt  is 
quite  difficult  to  manage,  being  decomposed  by  all  organic 
substances. 

lodifie  has  been  recommended  in  the  form  of  tincture,  either 
alone  or  combined  with  iodide  of  potassium.  Dr.  Lauton,  in  1865, 
boasted  of  the  juice  of  lemon  mixed  with  the  bruised  bulb  ol 
garlic.  Those  two  substances  had,  as  he  thought,  real  anti. 
septic  properties. 

Sulphur,  employed  locally  before  by  Jodin  as  a  parasiticide, 
has  been  given  internally  with  the  same  object.  It  is  adminis- 
tered in  the  form  of  washed  flour  of  sulphur,  of  which  10.  to  30 
{2^  jiO  to  15)  are  incorporated  with  honey.  One  may  also  mix  a 
tablespoonful  in  a  glass  of  water,  and  give  of  the  mixture  a 
tablespoonful  every  hour.  In  spite  of  the  marvelous  success 
referred  to  by  the  authors  of  this  treatment,    it  is   wise,    I  be- 


4IO  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

lieve,  to  maintain  a  prudent  reserve,  for  miracles  are  not  to  be 
revived. 

The  sulphites,  announced  as  antiseptics,  have  been  recom- 
mended by  Dr.  Giacchi.  The  author  uses  the  sulphite  of  mag- 
nesia in  broken  doses.  He  gives  6.  (172  5)  a  day.  Occasion- 
ally he  prescribes  at  the  same  time  the  sulphite  of  sodium  as  an 
enema:  Water,  500.  (17  5);  syrup  of  poppies,  50.  (I'AS)- 
sulphite  of  sodium,  50.  (1V2  o). 

Carbolic  acid  of  which  the  disinfectant  properties  are  so  cel- 
ebrated, could  not  fail  to  be  tried  in  diphtheria.  It  has  been 
employed  especially  in  the  form  of  syrup.  Its  compounds 
have  also  been  examined.  Roger  and  Peter  have  given  the 
carbolate  of  sodium;  this  remedy  has  appeared  in  some  cases  to 
have  beneficial  effects,  but  it  has  failed  on  many  occasions.  It 
is,  in  fact,  as  uncertain  as  the  others.  The  sulpho-carbolate  of 
quinia  has  been  tried  in  the  dose  of  .05  to  .20  (7^  to  3  grs.)  a 
day,  and  concurrently  with  the  use  locally  of  oxalic  acid,  by 
Drs.  Prota  Giurleo  and  Francesco,  of  Naples,  at  the  solicita- 
tion of  Dr.  Noah  Cinni,  of  Montefolcino.  This  practice  is  re- 
ported to  have  succeeded  in  all  the  cases! 

Salicylic  acid  has,  for  some  time  past,  been  highly  recom- 
mended as  being  powerfully  antiseptic,  and  is  said  to  posses 
all  the  properties  of  carbolic  acid  without  having  its  disadvan- 
tages. This  compound,  which  is  said  to  be  at  once  febrifuge 
and  tonic,  is  considered  by  Wagner  as  a  powerful  therapeutic 
agent.  It  is  said  to  greatly  abbreviate  the  duration  of  the  dis- 
ease. 

Dr.  Karl  Fontheim  is  said  to  have  obtained  by  this  remedy 
remarkable  success  of  which  the  details  surely  leave  little  to 
be  desired.  The  disease  continued,  at  the  maximum,  eight 
days,  and  three  or  four  days  at  the  minimum.  The  constitu- 
tional diphtheritic  infection  ceased,  albuminuria  disappeared, 
and  paralysis  was  prevented.  This  compound,  he  claims,  is  also 
prophylactic ;  in  numerous  families  it  limited  diphtheria  to  the 
persons  first  attacked.     The  following  is  the  formula  : 

]^     Acidi  salicylici,  2.  (72  5). 
Alcohol,  q.  s. 
Aquje,  200.  {j^li  §)•     M.  Teaspoonful  three  times  a  day. 


TREATMENT.  41  I 

It  was  used  at  the  same  time  as  a  gargle  and  a  local  appli- 
cation. It  is  difficult  not  to  entertain  some  doubt  about  the 
realization  of  such  an  attractive  programme,  and  one  is  tempt- 
ed to  ask  if  all  this  portrait  is  not  too  beautiful  to  be  true.  The 
method  deserves  a  trial ;  it  is  easy  to  manage  and  is  less  un- 
pleasant than  carbolic  acid.  Hence,  one  may  test  the  results 
obtained  by  the  German  authors,  though  he  may  end  in  a  new 
deception.  I  should  mention,  in  this  place  alcohol,  which  is 
one  of  the  best  antiseptics.  I  shall  have  to  speak  of  it  more  in 
detail  as  applicable  to  the  supporting  treatment. 

Conchision. — The  long  array  which  has  just  been  made  of 
the  above-mentioned  means  for  the  purpose  of  attacking  diph- 
theria in  its  essence  proves  once  more  that  the  list  of  remedies 
used  in  any  disease  are  in  proportion  inefficient  as  they  are 
greater  in  number.  The  specific  remedy  for  diphtheria  is  not 
yet  discovered.     We  may  doubt  if  it  ever  will  be. 

Among  therapeutic  agents  some  are  injurious  and  should 
be  rejected,  others  being  able  to  fulfill  certain  indications  shall 
be  used  according  to  the  cases. 

When  there  is  a  necessity  to  diminish  the  production  of  false 
membranes,  remedies  which  are  eliminated  by  the  buccal  or 
respiratory  mucous  membranes  and  by  the  salivary  glands  may 
be  employed ;  perhaps  they  may  exert  a  moUifying  influence 
on  the  vitality  of  the  mucous  membranes  in  such  a  way  as  to 
diminish  the  pseudo-membranous  exudation.  These  substan- 
ces will  be  brought  into  requisition  on  condition  that  their  use 
does  not  disgust  the  patient  too  much,  nor  interfere  with  ali- 
mentation, nor  produce  any  injurious  effect  upon  the  digestive 
apparatus. 

When  septicaemia  prevails,  that  must  be  attacked.  The 
means  are  no  longer  wanting.  The  best  of  ah  is  alcohol,  which 
may  be  given  in  the  form  of  various  kinds  of  wine  or  of  spirits 
and  water,  or  grog.  The  other  antiseptics  are  not  always 
inoffensive  when  taken  internally ;  moreover,  their  action  is  far 
from  being  demonstrated.  While  a  substance,  applied  di- 
rectly to  the  diseased  tissue  possesses  antiseptic  properties, 
there  is  no  proof  that  it  acts  in  the   same   manner  when  intro- 


412  DIPHTHERIA,  CROUP  AND  TRACHEOTOMY. 

duced  into  the  digestive  tract  and  taken  up  by  absorption. 
When  they  have  so  repulsive  a  taste  as  carboHc  acid,  we  may 
without  inconvenience  dispense  with  them.  It  would  be  bet- 
ter to  resort  to  the  perchloride  of  iron  which  at  least  possesses 
the  advantage  of  acting  as  a  ferruginous  remedy.  The  favor 
which  salicylic  acid  enjoys  abroad  may  induce  a  trial  of  this 
product  which  does  not  appear  to  produce  otherwise  injurious 
effects. 

B. — Restorative  Treatment. 

Alimentation.  Food  and  tonics  form  the  basis  of  this  treat- 
ment. We  cannot  too  strongly  insist  upon  the  necessity  of 
nutrition  in  diphtheria.  No  medication  can  replace  it.  All 
the  efforts  of  the  physicians  should  tend  to  have  nourishment 
taken  regularly.  When  the  appetite  is  preserved,  and  the  dys- 
phagia is  not  intense,  the  difficulties  are  not  so  great ;  but 
when  deglutition  is  painful,  when  anorexia  is  complete, 
which  is  most  frequently  the  case,  it  is  necessary  to  contend 
with  perseverance,  «sing  by  turns,  persuasion,  promises  and 
even  threatenings.  In  the  general  direction  of  the  treatment 
we  should  always  have  this  important  point  in  view.  All  med- 
icines susceptible  of  causing  disgust,  or  of  provoking  nausea, 
or  diarrhoea,  should  be,  without  hesitation,  dispensed  with.  I 
say  the  same  of  cauterization  and  painful  local  applications, 
which  increase  the  dysphagia  and,  consequently,  the  repug- 
nance for  alimentation.  Acting  otherwise  would  be  to  lose 
the  substance  for  the  shadow,  and  to  sacrifice,  for  means  of 
which  the  efficacy  is  doubtful,  the  only  one  of  which  the  effect 
is  always  beneficial,  the  only  one  indispensable. 

We  cannot  give  positive  rules  respecting  the  details  and  the 
form  of  food.  If  the  dysphagia  is  slight  and  the  appetite  suffi- 
cient, roasted  or  broiled  meat  and  soup  or  porridge  should  make 
the  basis  of  the  diet.  When  the  appetite  is  indifferent  or  gone,  it 
should  be  stimulated,  o.  tempted  by  dainties  the  most  agreea- 
ble to  the  patient :  oysters,  game,  dainty  dishes,  cream,  eggs  and 
milk  ;  one  may  contrive  variety.  The  nature  of  the  food  is  not 
important  provided   it  be  taken.     Avoid   insisting    on    certain 


TREATMEiNT.  4I3 

kinds  of  food  which  might  appear  more  appropriate ;  it  may- 
result  in  an  entire  refusal  on  the  part  of  the  patient.  A  nour- 
ishment which  appears  but  sHghtly  restorative  is  still  prefera- 
ble to  complete  abstinence.  The  patient  who  is  left  from  the 
first  to  his  own  indifference  about  food,  may  be  rescued  later 
only  with  the  greatest  difficulty.  If  dysphagia  is  the  principle 
obstacle  we  may^  have  recourse  to  semi-solid  food,  to  thick 
porridge  to  which  is  added  juice  of  meat,  vermitelli,  cream, 
soft  boiled  eggs,  the  soft  part  of  bread  soaked  in  the  juice  of 
meat,  or  meat  hashed  or  scraped  quite  fine. 

Alcoholics. — To  food  properly  so-called  it  is  necessary  to 
add  spirits  in  any  form  in  as  large  quantity  as  possible.  The 
preference  of  the  patient  should  be  still  scrupulously  followed, 
namely:  Bordeaux  wine,  the  alcoholic  wines,  dry  or  sweet; 
sherry,  Malaga,  champagne,  beer  and  sweetened  spirits  (grog), 
may  be  used  with  success.  The  only  precaution  consists  in 
diluting  these  drinks  with  a  certain  amount  of  water  and  giving 
them  by  small  quantities.  In  this  way  we  may  introduce 
quite  large  quantities.  Coffee  is  also  an  energetic  stimulant 
very  acceptable  to  children.  Of  all  the  antiseptics  given  in- 
ternally, alcohol  is  much  the  most  certain.  The  more  pro- 
nounced the  infection  is  the  more  necessary  it  is  to  insist  upon 
the  alcoholic  compounds.  Bricheteau  reports  the  history  of 
a  patient  attacked  with  a  spreading  pharyngo-laryngeal 
diphtheria,  which  extended  upon  the  blistered  surface  and  was 
accompanied  by  profound  adynamia.  Bordeaux  wine  was  ad- 
ministered, of  which  he  took  as  much  as  a  bottle  and  a  half 
a  day  without  experiencing  the  least  symptom  of  intox- 
ication or  headache.  I  am  always  careful  to  follow  a  similar 
course  by  taking  in  every  case  the  precaution  to  test  the  sus- 
ceptibility of  the  patient  in  this  respect. 

Tonics. — Quinine  ought  also  to  occupy  a  large  place  in  the 
treatment  of  diphtheria.  I  prescribe  it  constantly  in  the  form 
of  soft  extract,  in  quantity  of  2.  to  4.  (^/.,  5  to  i  3)  a  day,  in  an 
infusion  of  coffee.     It  may  be  formulated  thus  : 

Infusion  of  coffee,  125.  (43). 

Syrup  of  gum  accaia,  40.  (174  5). 


414  DIPHTHERIA,  CROUP    AND    TRACHEOTOMY. 

Soft  extract  of  cinchona,  2.  to  4.  (72  to  i  3).  Dose,  a  table- 
spoonful  every  two  hours. 

It  may  be  also  employed  in  the  form  of  aqueous  infusion, 
four  teacupfuls  during  the  day,  sweetened  or  not.  Trousseau 
gave  I.  to  2.  (15  to  30  grs.)  of  the  powder  of  yellow  cinchona 
bark  or  0.25  (4  grs.)  of  sulphate  of  quinine,  in  coftee.  Cinchona 
bark  with  malaga  wine  and  syrup  is  still  much  used  ;  they 
have  the  single  inconvenience  of  requiring  too  large  a  vehicle 
for  the  same  dose  of  the  active  principle. 

Iron  finds  also  its  indication  in  diphtheria,  especially  when 
the  patient  is  convalescent,  and  it  is  necessary  to  attack 
anaemia  when  it  has  reached  its  maximum.  The  ferrated  wine 
of  cinchona  well  prepared,  the  syrup  of  citrate  of  iron  and 
dialysed  iron  are  the    most  acceptable  pharmaceutical    forms. 

Cold. — By  virtue  of  their  tonic  action  the  practice  of  hydro- 
pathy should  be  counted  among  the  general  modifiers  which 
have  been  used  to  combat  diphtheria. 

In  Germany,  especially,  this  method  has  been  brought  into 
notice.  Harder,  Baumbach,  Diitersberg  and  Bischof  recom- 
mend cold  affusions.  The  child  is  placed  in  a  bath-tub, 
then  some  one  pours  upon  the  posterior  part  of  the  body  two 
bucketfuls  of  water  at  a  temperature  of  12°  or  13°  (54° — 56°  F.) 
Manner,  physician  to  the  children's  hospital  at  Munich,  uses, 
in  preference,  wrapping  in  a  wet  sheet  and  then  covering  with 
a  blanket.  The  patient  is  left  in  this  situation  until  full  reac- 
tion occurs.  The  author  surrounds  the  neck  also  with  a  cloth 
wet  in  ice  water.  This  system  was  practised  by  Delacoux  in  a 
case  of  angina  treated  with  caustics,  and  threatening  the  lar- 
ynx. He  substituted  the  treatment  thus  commenced,  by  ap- 
plying to  the  neck  a  compress  wet  in  cold  water  with  Labar- 
raques'  solution  added,  and  renewed  it  every  hour.  A  very 
perceptible  amelioration  soon  followed,  and  the  patient  recov- 
ered. 

Dr.  Klee  reports,  according  to  Dr.  Alexandre,  the  case  of  a 
patient  attacked  with  a  grave  diphtheria  of  the  throat  and 
nose,  complicated  with  cerebral  symptoms,  convulsions,  risus 
sardonicus  and  coldness  of  the  extremities   coincident  with  an 


TREATMENT.  415 

elevation  of  the  temperature  of  the  body.  Antispasmodic 
remedies  produced  no  effect,  and  death  was  approaching.  The 
child  was  sponged  off  twice  with  cold  applications  which 
calmed  him  immediately.  German  physicians  seem  quite  sat- 
isfied with  affusions  and  the  wet  wrapping.  But  the  facts 
which  they  produce  in  its  support  are  few  and  inconclusive. 
Besides,  this  method,  that  of  Hanner  in  particular,  is  not  with- 
out danger ;  it  requires  to  be  applied  with  the  greatest  precau- 
tions. In  fact,  one  cannot  too  much  dread  the  thoracic  com- 
plications of  diphtheria.  It  is  necessary,  above  all,  to  guard 
against  producing  any  occasion  for  them,  or  opening  the  way 
to  them.  If  I  should  judge  by  the  application  that  I  have  seen 
made  of  the  system,  it  would  be  necessary  to  abridge  the  suc- 
cess announced.  However,  the  indication  for  this  method 
may  present  itself.  The  ordinarily  slight  intensity  of  the  fever  in 
diphtheria  rarely  gives  occasion  for  the  application  of  cold  as 
a  diminisher  of  excessive  caloric.  On  the  contrary,  the 
adynamia  and  the  ataxic  symptoms  permit  the  rational  use  of 
the  method,  and  from  it  we  may  obtain  real  neurosthenic  ef- 
fects. In  this  case  the  cold  ablution  made  rapidly  and  followed 
by  wrapping  in  a  blanket,  will  be  a  useful  application.  Cold 
has  not  only  been  applied  to  the  surface,  but  ice  and  cold 
drinks  have  been  used  internally.  All  tends  to  the  belief  that 
in  this  way  it  acts  still  as  a  tonic. 

Dr.  Violette  reports  that  in  a  child,  reduced  by  repeated  vom- 
itings and  at  the  same  time  by  free  and  obstinate  epistaxis,  to 
an  advanced  degree  of  adynamia,  this  treatment,  by  the  advise 
of  Barthez,  was  replaced  by  tonics  internally  and  insufflations 
of  tannin.  The  debility  having,  however,  continued,  Violette 
added  to  this  treatment  pounded  ice  given  night  and  day  by 
teaspoonfuls  every  ten  minutes.  Twelve  hours  afterwards 
the  improvement  was  considerable ;  recovery  was  accom- 
plished. 

This  method  approximates  that  of  Dr.  Grandboulogne,  who 
advocates  the  constant  use  of  ice.  Lacaze  in  a  very  severe  and 
very  fatal  epidemic  which  prevailed  in  the  island  of  Reunion 
(one  of  the  Mascarene  islands),  was  well  pleased  with  the    fol- 


4l6  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

lowing  system  :  Iced  drink  of  tamarinds,  astringent  gargles, 
and,  from  time  to  time,  pieces  of  ice  taken  in  the  mouth. 
When,  on  account  of  tender  age,  the  gargle  could  not  be  pre- 
scribed, he  injected  every  half  hour,  into  the  throat  and  nose, 
simple  ice  water. 

This  treatment  seems  to  be  commonly  employed  in  the 
United  States,  according  to  the  report  of  Dr.  Colson  ;  it  is  also 
commended  in  England  by  Dr.  West.  In  this  local  applica- 
tion the  cold  appears  to  act  especially  as  a  tonic.  The  anti- 
phlogistic action  is,  in  Hict,  of  little  importance,  in  diphtheria 
the  inflammation  being,  generally,  but  slightly  intense,  and 
constituting  but  one  of  the  secondary  elements  of  the  disease. 
When  adynamia  prevails,  or  h3emopt}'sis  is  manifest,  the  tonic 
action,   local  and  general,  of  ice  may  be  favorable. 

Conchision. — None  of  the  means  above  cited  have  the  power 
of  preventing  the  production  of  false  membranes.  Therefore 
none  of  them  exercise  upon  diphtheria  a  curative  action  prop- 
erly so-called.  Hence,  the  specific  of  this  disease  remains 
still  to  be  discovered.  Will  it  ever  be  ?  That  is  not  probable. 
All  tends  to  the  belief  that  it  no  more  exists  than  does  one  for 
typhus  fever,  or  for  measles,  etc.  To  persist  in  the  search  of 
such  means  is  to  direct  medicine  in  a  false  channel.  A  well- 
chosen  treatment  of  diphtheria  ought  to  be  regulated  not  to 
the  disease,  but  to  the  patient  and  to  the  indications  which  he 
furnishes. 

SECOND  CLASS. 

Treatment  of  the  Local  Manifestations  of  Diphtheria. 

Independently  of  the  general  indications  inherent  to  diph- 
theria itself,  each  local  manifestation  becomes,  by  reason  of 
the  organ  attacked,  the  source  of  special  indications. 

§  I. — Diphtheritic  Angina.  {^Faucal  Diphthend). 

This  local  manifestation,  [localizatioii)  the  most  common  of 
all,  is  also,  except  cutaneous  diphtheria,  which  is  rare,  the  one 
which  presents  false  membranes  the  most  accessible  to  thera- 
peutic agents.     Against  this  form   are  first  directed   the  local 


TREATMENT.  4^7 

means  collected  by  art  for  diphtheria.  For  this  reason  I  de- 
sire to  present,  in  this  place,  the  history  of  the  local  modifiers. 
Physicians  of  all  periods  have  endeavored  to  destroy  the  false 
membranes,  I  have  shown  that  quite  frequently  this  practice 
has  not  the  advantage  which  has  been  accorded  to  it ;  but  as  it 
may  be  indicated  in  certain  cases,  I  ought  to  pass  in  review  the 
means  that  have  been  employed  to  that  end. 

Local  modi fiei's. — Several  principal  methods  have  been  made 
use  of ;  their  mode  of  action  are  as  caustics,  astringents,  sol- 
vents, antiseptics  and  parasiticides. 

Of  cauterization. — This  system,  as  old  as  the  disease,  since 
it  goes  back  to  Aretaeus,  was  conceived  in  the  idea  that  diph- 
theria was  primarily  a  local  disease,  becoming  general  by  the 
absorption  of  septic  products  formed  on  the  surface  of  the 
false  membrane,  and  gaining  in  extent  by  contiguity.  To 
avoid  infection  and  propagation  the  disease  must  therefore  be 
destroyed  on  the  spot,  and  at  once,  or  at  least,  be  essentially 
modified.  From  the  red  hot  iron  to  the  mildest  class  of  caus- 
tics, a  large  number  of  caustics  have  been  applied  to  the  diph- 
theritic exudates.  , 

A. — Caustics. 

Hydi'ochloric  acid. — Boasted  of  by  Van  Swieten,and  Marteau, 
of  Grandvilliers,  recommended  by  Bretonneau,  Trousseau  and 
Guersant,  this  caustic  was  used  absolutely  pure,  fuming  as 
Trousseau  preferred  it,  or  mixed  with  one-third  or  one-fourth 
of  honey  of  roses,  according  to  Guersant.  According  to  Trous- 
seau this  acid  in  a  pure  state  did  not  produce  cauterization 
deeper  than  that  of  nitrate  of  silver ;  at  any  rate,  it  did  not 
have  the  deep  action  of  analogous  substances,  such  as  sulphuric 
acid  and  nitric  acid.In  admitting  the  correctness  of  this  assertion, 
verified  also  by  other  authors,  it  is  none  the  less  true  that  the 
cauterization  of  the  throat  with  hydrochloric  acid  is  excessively 
painful  and  not  exempt  from  danger. 

SulpJiuric  acid  and  nittic  acid  are  means  more  energetic, 
more  painful,  still  more  dangerous  and  produce  deeper 
eschars. 


4l8  DIPHTHERIA,     CROUP    AND    TRACHEOTOMY. 

The  actual  cautery  applied  by  some  physicians  has 
never  had  but  a  limited  use.  It  is  a  violent,  painful,  and  tear- 
fully dangerous  means.  Trousseau,  such  a  great  partisan  of 
cauterizations,  considered  it  as  only  applicable  to  cutaneous 
diphtheria.  Caustic  soda  used  by  Roger  and  Peter  in  the  ex- 
periments made  with  Reveil,  performs  a  double  action. 
While  it  is  caustic,  it  exerts,  at  the  same  time,  upon  the  false 
membranes  a  rapid  solvent  power.  In  this  respect,  it  might 
be  classed  with  solvents,  and  be  employed  profitably  ;  but  its 
other  effect  would  rather  classify  it  with  the  caustics,  admit- 
ting that  there  are  solvents,  the  local  action  of  which  is  harm- 
less. 

Catherctics — Mild  caustics. — At  the  head  of  this  list  must  be 
placed  nitrate  of  silver  of  which  the  use,  after  having  been  uni- 
versal, is  still  by  the  force  of  habit  continued  by  a  large  num- 
ber of  physicians.  The  crayon  is  found  in  the  pocket-case  of 
every  one,  and  its  application  is  very  easy.  These  are  two 
conditions  important  to  success  which  will  keep  it  for  a  long 
time  in  favor.  It  is  used  in  the  solid  state  or  in  solution  of 
one-fourth,  one-third  or  of  equal  parts.  The  crayon  is  in  more 
extensive  use  because  it  is  convenient ;  the  solution  is  less 
liable  to  the  inconvenience  of  producing  upon  the  mucous 
membrane  a  white  exudation  resembling  a  false  membrane. 
In  applying  the  solution  a  camel's  hair  brush,  a  bit  of  charpie, 
or  a  little  sponge  rounded  off  and  fastened  to  a  sponge-holder 
or,  what  is  better,  to  a  flexible  rod  or  a  whalebone,  is  wet  in 
it.  It  is  necessary  to  squeeze  out  the  excess  of  fluid  before 
making  the  application  to  the  throat,  in  order  to  avoid  having 
the  caustic  run  into  the  esophagus  or  into  the  larynx. 

The  sulphate  of  copper  in  saturated  solution  was  employed 
by  Trousseau  in  preference  to  the  nitrate  of  silver.  It  has  not 
the  disadvantage  of  the  latter  of  indelibly  staining  the  clothing. 

Perchloride  of  iron. — Before  being  given  internally  this  rem- 
edy was  extolled  as  a  local  application. 

Hatin,  Gigot,  of  Levroux,  and  Sylva  spoke  highly  of  its 
advantages.  It  is  also  recommended  by  Prof.  Steiner.  It  is 
said  to  have  a  mummifying  action    upon  the  false  membranes, 


TREATMENT.  419 

to-wit :  those  which  are  thin  and  sh'ghtly  adherent  become  im- 
mediately detached  ;  the  more  resistant  are  separated  only  in 
patches  like  fragments  of  muscle  macerated  in  water.  This  local 
application  is  reported  to  possess  the  farther  advantage  of  con- 
stringing  the  subjacent  tissues,  and  of  preventing  new  membra- 
nous exudations.  One  should  make  twice  during  the  first  24  hours, 
an  application  of  the  officinal  solution  of  perchloride  of  iron 
by  means  of  a  hair  pencil  or  a  sponge.  In  spite  of  these  advan- 
tages the  perchloride  of  iron  does  not  prevent  the  reproduction 
of  talse  membranes  any  more  than  other  local  applications.  It 
has,  moreover,  the  Inconvenience  of  being  a  painful  application, 
more  so  than  that  of  nitrate  of  silver.  The  facts  observed  by 
Moynier,  Fischer  and  Bricheteau,  Barthez  and  myself,  furnish 
the  proof  of  it.  Besides,  it  has  a  very  disagreeable  taste 
which,  added  to  the  dysphagia  which  it  produces,  still  increases 
the  children's  repugnance  for  food. 

Iodine. — Tincture  of  iodine  has  been  used  in  the  form  of 
paint  upon  the  false  membranes  by  Perron,  of  Alexandria,  and 
Zurkowski.  According  to  the  former  physician  this  applica- 
tion is  very  painful.  This  must  be  taken  into  consideration, 
though  Boinet  denies  the  truthfulness  of  it  and  asserts  that  the 
tincture  of  iodine  applied  to  the  mucous  membranes  produces 
but  moderate  pain.  Guersant  advocated  the  use  also  of  the 
acid  sulphate  of  alumina  in  a  solution  of  one  to  three  or  one 
to  four  of  water. 

General  Rules. — Every  time  that  we  make  use  of  cauteriza- 
tion of  the  throat,  it  is  necessary  to  have  the  patient's  head 
firmly  held  by  an  assistant.  It  does  not  matter  whether  the 
patient  lies  down  or  sits  up.  The  throat  should  be  thoroughly 
illuminated.  During  daylight  the  face  should  be  turned  to- 
wards a  window.  If  this  cannot  be  done,  or  if  the  application 
should  be  needed  in  the  evening,  the  light  of  a  candle  fur- 
nished with  a  reflector  should  be  thrown  into  the  throat;  a 
simple  silver  spoon  may  answer  as  a  reflector.  But  when  there 
is  less  urgency  it  is  preferable  to  operate  by  daylight,  and  to 
have  the  patient  seated  on  the  lap  of  an  assistant  sitting  in 
Iront  of  a  window.       This  is  the  best  way  to  fully  understand 


420  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

what  one  is  doing.  A  second  assistant  holds  the  head  con- 
veniently. A  tongue  depressor  introduced  to  the  base  of  the 
tongue  enables  one  to  strongly  depress  this  organ  and  obliges 
the  patient  to  hold  the  mouth  wide  open.  The  caustic  is  then 
applied  quickly  upon  the  diseased  parts  by  means  of  a  little 
brush  or  sponge ;  the  healthy  parts  should  be  spared  as  much 
as  possible.  When  the  operation  is  terminated  it  is  well  for 
the  patient  to  rinse  the  mouth  in  order  to  dilute  and  remove  the 
excess  of  the  caustic  which  might  spread  about.  If  the  patient 
is  quite  young,  the  mouth  should  be  washed  out.  The  liquid 
for  the  gargle  or  for  the  wash  may  be  simply  pure  water  or  a 
liquid  which  neutralizes  the  free  caustic  remaining.  In  the 
case  of  cauterization  with  nitrate  of  silver,  salt  and  water  is 
proper;  after  caustic  soda,  vinegar  and  water  is  indicated. 

Cauterization  is  generally  abandoned  ;  it  has  serious  disad- 
vantages ;  it  is  dangerous,  and  it  is  useless. 

It  is  dangerous. — However  dextrous  the  operator,  however 
tractable  the  patient  may  be,  it  is  difficult  to  limit  the  action 
of  the  caustic  to  the  false  membranes ;  a  certain  amount  of  it 
always  extends  upon  the  neighboring  parts  which  it  inflames. 
When  thus  irritated  these  become  covered  with  diphtheria,  or 
with  eschars,  as  in  cauterization  with  hydrochloric  acid,  or 
with  a  pultaceous  coating,  as  after  the  use  of  nitrate  of  silver. 
These  new  products,  possessing  great  analogy  to  the  forming 
diphtheritic  false  membrane,  are  seen  when  the  physician 
makes  another  examination ;  he  suspects  the  extension  of  the 
disease,  and  recommends  more  than  ever  cauterization.  If  he 
escapes  this  mistake,  he  is  still  more  embarrassed ;  in  fact 
eschars  and  false  membranes  are  confounded  in  one  in  which 
it  is  impossible  to  tell  the  progress  of  the  disease.  Eschars, 
often  extensive  and  deep,  and  the  attachments  of  diphtheria 
to  points  remaining  healthy,  are  therefore  consequences  much 
more  frequent  than  we  suppose.  Barthez  has  several  times 
seen  the  production  of  vast  eschars  under  the  influence  of  this 
cause.  Thence  arose  these  aggravations  of  the  disease,  which 
did  not  escape  the  great  practical  sense  of  Trousseau,  partisan 
of  cauterization    as  was    this    illustrious'  clinician.     But    what 


TREATMENT.  421 

may  not  happen  when  the  operator  is  httle  experienced,  and 
the  patient  resists,  as  is  most  usually  the  case  !  A  child  that 
has  been  taken  once  by  surprise,  will  not  suffer  himself  to  be 
taken  off  guard  a  second  time,  and  will  resist  with  all  his  might. 
It  is  understood  that  cauterization  is  then  made  at  random 
and  that  the  disadvantages  before  cited  are  inevitable 
and  more  serious.  The  patient  is,  in  fact,  not  so  well  held,  the 
tongue  is  imperfectly  depressed,  and  the  caustic  is  blindly 
splattered  around  on  the  tongue,  on  the  palate,  etc.  Some  ac- 
cidents still  much  more  serious  are  produced.  If  one  has  not 
taken  the  precaution  to  strongly  squeeze  the  sponge  or  the 
brush  wet  with  the  caustic,  the  contraction  of  the  muscles  of 
the  isthmus  compresses  it  and  it  spreads  the  fluid  in  the  throat. 
It  may  be  swallowed  and  spread  in  the  esophagus  as  Cambre- 
lin  has  shown ;  it  may  also  pass  into  the  larynx,  where  it 
causes  cauterization,  oedema  of  the  glottis,  etc.  It  also  hap- 
pens that  the  patient  sometimes  closes  suddenly  his  mouth 
before  the  instrument  is  withdrawn.  Trousseau  and  Blache 
have  witnessed  this  accident  and  its  sad  consequences,  espec- 
ially when  the  cauterization  is  made  with  hydrochloric  acid. 
The  consequences  are  less  serious  when  the  cauterization  is 
made  with  nitrate  of  silver.  However,  the  crayon  has  been 
known  to  be  crushed  between  the  teeth  and  swallowed. 

I  was  recently  called  to  a  child  who  had  suddenly  closed  the 
jaws  while  an  application  was  being  made  to  the  throat  with  a 
brush  dipped  in  a  solution  of  nitrate  of  silver.  The  entire 
mouth  had  been  burned  and  presented  one  large  white  surface. 
Fortunately  the  solution  was  not  very  strong.  Several  authors, 
Guyet  among  others,  have  cited  cases  of  sudden  death  by 
spasm  of  the  larynx,  following  as  a  consequence  of  painful  cau- 
terization. 

The  pain  resulting  from  cauterization  is  added  to  the  dys- 
phagia natural  to  angina  and  to  the  taste  of  caustic  which  is 
nearly  always  disagreeable,  so  as  to  make  feeding  impossible. 
The  struggle  that  the  patient  makes  in  resisting  at  each  cau- 
terization diminishes  his  strength.  The  preservation  and  aug- 
mentation of  the  strength  are  indications   much   more    impor- 


422  DIPHTHKRIA,    CROUP    AND    TRACHEOTOMY. 

tant  than  the  modification  of  the  false  membranes.  All 
excitement,  all  struggling  should  be  avoided  ;  quiet,  the  most 
perfect  should  be  prescribed.  All  local  medication  that  in- 
fringes this  rule  should,  for  that  reason  alone,  be  rejected,  how- 
ever much  extolled  may  be  its  effects ;  the  patient  must  not 
die  of  the  remedy. 

//  is  useless.— Cdixxstxcs  have  no  influence  upon  the  general 
disease.  If  they  remove  the  false  membrane,  most  frequently 
detaching  little  pieces,  they  prevent  in  no  way  the  reproduc- 
tion of  the  exudate.  They  arrest  in  no  respect  either  its  exten- 
sion or  its  propagation  towards  the  larynx.  Many  cases  of 
angina,  on  the  contrary,  from  which  this  treatment  has  been 
withheld,  remain  limited  to  the  throat.  One  will  not,  there- 
fore, be  astonished,  admitting  such  results,  that  cauterization 
is  universally  abandoned  by  enlightened  physicians  in  France 
and  abroad. 

In  France,  Cambrelin,  Bricheteau  and  Barthez  are  opposed 
to  this  method.     It  is  no  longer  practised  in  the  hospitals. 

/;/  England,  at  the  Harveian  Society,  Drs.  Cleveland,  Her- 
ville,  Greenhow  and  Hillier  have  unanimously  pronounced 
against  cauterization,  which  they  regard  as  more  injurious  than 
beneficial.  Local  astringents,  and  tonics  given  internally,  ap- 
pear to  them  the  best  treatment. 

In  America,  Meigs  and  Pepper  express  the  same  sentiment. 
Dr.  Colson  informs  us  also  that  American  physicians  reject 
this  method  and  employ  especially  the  perchloride  of  iron,  the 
chlorate  of  potassium,  and  ice  internally  and  externally. 

In  Germany  cauterization  is  declining  more  and  more.  In  a 
discussion  which  occurred  in  1872,  at  a  session  of  the  Medical 
Society  of  Berlin,  of  which  I  have  before  spoken,  Dr.  Walden- 
burg  opposed  this  means,  and  nearly  all  the  physicians  present 
had  similar  views.  The  opinion,  therefore,  upon  the  value  of 
cauterization  is  at  present  fixed.  Its  abandonment  is  general 
and  justified. 

B. — Removal  of  the  Tonsils. 
Suggested  by  Bouchut,  this  practice  should  be  classed  with 


TREATMI.NT  423 

cauterization.  Its  object  is  the  same.  It  undertakes  to  des- 
troy the  mischief  on  the  spot,  and  to  prevent  infection  of  the 
economy.  It  was  said  to  be  an  excellent  preventive  means  of 
croup.  The  false  membranes  were  said  not  to  be  reproduced 
upon  the  wound  of  the  tonsils.  Notwithstanding  certain  for- 
tunate cases  reported  by  several  physicians,  this  therapeutic 
method  has  had  no  other  result  than  to  give  a  denial  to  the 
theory  which  it  should  have  sustained.  Not  only  was  the  pro- 
pagation of  the  disease  not  arrested,  but  the  wound  of  the  ton- 
sils became  covered  with  false  membranes.  Though  this  means 
did  not  succeed  better,  it  may,  however,  when  employed  with 
a  different  object,  render  unquestionable  service.  When,  by 
their  enormous  size,  the  tonsils  obstruct  respiration  or  degluti- 
tion, the  patient  finds  a  decided  relief  in  their  removal.  Only 
a  purely  mechanical  result,  it  is  true,  is  produced  thereby ; 
diphtheria  itself  is  in  no  wise  modified  ;  the  wounds  may  even 
become  covered  with  false  membranes,  but  in  such  a  case,  this 
consideration  becomes  secondary,  the  principal  indication  has 
been  met. 

C. — Astringents. 

These  remedies  claim  to  act  upon  the  tissues  by  constring- 
ing  them,  giving  them  tone,  and  whilst  shriveling  the  false 
membrane,  hasten  thus  its  separation. 

The  principal  ones  are :     Alum,  tannin  and  borax. 

^-J/7/;«.—Aretaeus  prescribed  it  by  insufflation,  or  incorporated 
it  in  honey.  After  having  fallen  into  desuetude  for  ages  it  was 
restored  by  Trousseau  who  saw  it  used  by  an  empiric,  during  an 
epidemic  which  he  observed  in  Sologne.  This  remedy  has  the 
advantage  of  being  easily  applied,  little  painful,  found  every- 
where, and  cheap.  It  is  used  as  a  gargle  or  as  a  mouth-wash 
in  a  dose  of  about  4.  (i5).  But  its  use  is  generally  in  the  form 
of  insufflations.  This  was  the  method  of  Areta;us ;  in  insuf- 
flating, it  was  carried  to  the  bottom  of  the  pharynx  by  means  of 
a  tube,  or  a  hollow  reed,  or  elder  from  which  the  pith  has  been 
removed.     Trousseau  used  it  the  same  way.     At   present   the 


424  DIPHTHERIA,  CROUP  AND  TRACHEOTOMY. 

application  is  made  much  more  simply  with  a  gum  pouch  at- 
tached to  a  canula.  The  dose  is  not  important ;  it  should  be 
sufficient  to  cover  freely  the  diseased  surfaces  with  the  pow- 
der. In  the  case  of  a  child  the  physician  takes  his  position  as 
in  cauterization,  and  places  the  insufflator  in  the  throat,  or  the 
brush  filled  with  the  wash.  The  first  method  has  the  great 
advantage  of  not  being  painful  and  not  provoking  nausea.  The 
insufflation  should  be  made  eight  or  ten  times  during  the  twen- 
ty-four hours  ^or  the  first  few  days. 

Tannin. — This  remedy  is  employed  in  the  same  dose  and  un- 
der the  same  form  as  alum.  Aretaeus  used  gall-nuts  as  a 
mouth-wash  and  in  insufflations.  To  render  this  medication 
still  more  powerful,  one  may,  following  the  advice  of  Loiseau, 
of  Montmartre,  alternate,  every  quarter  of  an  hour,  the  insuffla- 
tions of  alum  with  those  of  tannin.  This  method  is  one  which 
has  given  the  best  results,  and  has  been  employed  by  a  large 
number  of  physicians.  Barthez  has  often  witnessed  from  it 
good  local  effects.  Insufflations  may  be  replaced  by  inhala- 
tions. For  this  purpose  a  solution  strongly  charged  with  tan- 
nin is  placed  in  an  atomizer.  The  operation  is  repeated  five 
or  six  times  a  day.  It  has  little  practicability  for  children,who 
ill-submit  to  the  applications  which  are  a  little  too  prolonged 
for  them. 

Borax. — It  is  applied  like  the  previous  ones,  either  as  a  gar- 
gle, a  wash,  or  by  insufflations.  The  doses  are  the  same  as  well 
as  the  effects. 

Sulphur. — Suggested  by  Jodin  as  being  beneficial  on  the 
score  of  a  parasiticide,  sulphur  has  been  prescribed  by  other 
observers  who  were  less  pre-occupied  with  theoretical  ideas. 

Professor  Barbosa,  of  Lisbon,  author  of  remarkable  memoirs 
on  croup,  has  collected  and  published  eighteen  cases  of  child- 
ren and  adults  attacked  with  diphtheritic  angina,  and  treated 
by  the  insufflation  of  unwashed  flowers  of  sulphur  (sulphur  sub- 
limatum)  made  every  three  hours  in  the  most  serious  cases, 
and  every  four  hours  in  those  of  moderate  gravity,  and  three 
times  a  day  in  the  benign  cases.  From  the  next  day  the  false 
membranes  diminished  in  thickness,  in  extent  and    in    consis- 


TREATMENT.  425 

tence ;  they  assumed  a  creamy  appearance  and  disappeared 
on  the  fourth  day.  We  should,  according  to  the  advice  of  this 
author,  cover  all  the  false  membranes  with  the  sulphur,  and  a 
large  part  of  the  surrounding  mucous  membrane  without  fear- 
ing to  use  too  much,  this  powder  being  perfectly  innocent. 
The  first  application,  and  even  those  that  follow,  nearly  always 
provoke  contractions  of  the  pharynx,  cough,  and  sometimes 
vomitings  which  remove  all  the  powder.  It  is  necessary  then 
to  recommence  the  insufflation  until  tolerance  is  effected. 
When,  for  any  reason,  the  insufflation  cannot  be  practiced, 
sulphur  should  be  applied  either  in  the  form  of  a  mouth-wash, 
or  even  internally  as  an  electuar}\  The  insufflations  should  be 
directed  towards  all  the  accessible  parts,  in  the  throat,  and  in 
the  nasal  fossse  and  larynx  if  possible.  In  a  quite  recent  com- 
munication with  which  Barbosa  has  kindly  favored  me,  the 
learned  professor  insists  very  specially  upon  the  really  "admi- 
rable" effects  of  this  medication.  The  distinguished  ability 
that  all  recognize  in  him  in  such  matters,  imposes  a  duty  of  re- 
peating these  interesting  experiments.  This  remedy  is  also 
recommended  in  the  same  form  by  Dr.  Ullersperger.  Dr. 
Alban  Liitz  adds  to  the  insufflation  a  gargle  in  which  the  flow- 
ers of  sulphur  is  suspended  in  an  emulsion  : 

Flowers  of  sulphur,     -         -         -       2.50  (40  grs.) 
Oil  of  sweet  almonds,     -         -        180.       (60). 
M. 

What  is  the  modus  operandi  of  sulphur  administered  by  this 
method  ?  If  we  consider  that  the  authors  who  employ  it,  rec- 
ommend the  use  of  the  unwashed  flowers  of  sulphur,  we  may 
ask  if  the  active  principle  is  not  the  small  quantity  of  sulphur- 
ous and  sulphuric  acids  which  the  crude  flowers  of  sulphur  al- 
ways contains. 

Alcohol. — Much  spoken  of  by  the  English,  who  use  it 
either  pure,  painting  it  on,  or  diluted  with  equal  parts  of  water 
as  a  gargle,  this  liquid  has  never  had  any  well  marked  action. 

Oxalic  acid. — Quite  recently  this  article  has  been   tried  by 


426  DIPHTIIKKIA,    CROUr    AND    TRACHEOTOMY. 

Prota-Giurleo  and  Francesco,   of  Naples.       It   should  be  em- 
ployed bybrusliing  on  with  a  solution  as  follows: 

Oxalic  acid         -  -  -  -  I-  (i5  grs.) 

Distilled  water  -  -  -  -  20.  (50.)  M. 

or     Oxalic  acid         _  -  -  -  15.(72.5.) 

Glycerine  .  .  -  -  100.  (3.5.)     M. 

At  the  same  time  the  authors  give  internally  the  sulpho-car- 
bolate  of  quinine.  They  abstain  from  cauterization  which  they 
consider  as  dangerous. 

Kn  resume,  the  astringent  method,  exempt  from  dangers, 
much  more  easy  of  application  than  the  previous,  constitutes 
really  an  undisputable  advance.  It  has,  however,  still  the  in- 
convenience of  irritating  quite  decidedly  the  throat,  and  of 
leaving  a  persistent  disagreeable  taste  in  the  mouth,  and  thus 
presenting  an  obstacle  to  taking  food. 

D, — Solvents. 

Impressed  with  the  inherent  defects  of  caustics  and  of 
astringents,  several  physicians  have  sought  for  medicinal 
agents  which  would  exercise  a  solvent  action  upon  the  false 
membranes  without  attacking  the  neighboring  tissues.  The 
composition  of  the  exudate  being  fibrinous,  the  problem  con- 
sists in  finding  solvents  for  the  fibrin  which  might  not  be  irri- 
tant. 

Chemistry  teaches  that  the  acids,  the  alkalies  and  the  mer- 
curials dissolve  fibrin.  It  remains  to  choose  from  among  these 
substances  those  which  are  harmless  for  the  healthy  tissues. 
Among  the  alkalies,  the  bicarbonate  of  sodium,  ammonia,  and 
lime-water  have  been  tried.  With  the  list  of  alkalies  should 
be  placed  the  neutral  salts,  which  have  a  strong  analogy  to 
them;  they  are  chlorate  of  potassium,  chlorate  of  sodium  and 
the  iodate  of  potassium.  From  the  acids  we  should  reject  the 
mineral  acids  of  which  we  wish  to  avoid  the  caustic  effect.  The 
organic  acids,  such  as  the  citric  acid  and  lactic  acid,  have  been 
studied  in  this  respect.  The  mercurials  have  furnished  calomel 
and  red  precipitate.  To  this  list  must  be  added  a  metalloid, 
bromine,  which  presents  analogous   effects. 


TREATMENT.  42/ 

In  the  chapter  on  pathological  anatomy  is  found  the  list  of 
substances  which  ha\-    solvent  properties. 

Those  whose  clinical  value  has  been  proved  are  the  only 
ones  which  we  may  consider  here. 

1st.  Alkalies. — Bicarbonate  of  Sodium. — At  the  same  time 
that  this  medicine  is  given  internally,  it  is  prescribed  as  a  local 
application  either  by  insufflations  or  by  gargles.  The  treat- 
ment of  diphtheritic  angina  by  gargles  of  eau  d'Vichy  is 
very  extensive.  "Is  it  efficacious?  I  do  not  deny  its  utility  in 
cases  in  which  the  false  membranes  are  thin  ;  but  when  they 
are  thick  and  resistant,  the  salt  of  Vichy,  because  of  its  slight 
action  upon  these  products,  cannot  have  a  very  energetic  ther- 
apeutic value. 

Avinioiiia. — Barbosa,  of  Lisbon,  has  proved  the  solvent 
properties  of  a  mixture  of  equal  parts  of  glycerine  and  aqua 
ammoniae.  If  there  is  still  danger  of  its  irritant  action,  the 
proportion  of  glycerine  may  be  increased  in  this  mixture. 

Aqua  Calcis. — Brought  forward  by  Kiichenmeister,  the  sol- 
vent power  that  this  preparation  exercised  upon  the  diphthe- 
ritic false  membranes  was  applied  throughout  Germany.  Bier- 
mer,  of  Bern  (1864)  gave  it  great  praise.  In  a  previous  work 
I  have  repeated  the  experiments  of  these  authors  and  made 
numerous  clinical  trials.  Since  that  period  the  treatment  of 
diphtheria  with  lime-water  has  been  established  in  practice.  In 
France,  England  and  Germany  it  has  numerous  partisans. 
Quite  recently  Prof  Steiner  extolled  its  beneficial  effects.  It 
may  be  used  in  several  ways  :  as  a  gargle,  by  inhalations  and 
by  irrigations.  Gargling  is  an  excellent  method  when  the  pa- 
tient can  so  use  it ;  this  must  not  be  expected  before  the  age 
of  six  or  eight.  Lime-water  may  be  used  pure,  but  in  some 
cases  it  slightly  excoriates  the  lips.  It  is  better  to  add  equal 
parts  or  half  the  weight  of  milk.  The  gargling  should  be  made 
as  frequently  and  as  prolonged  as  possible.  During  the  oper- 
ation the  patient  should  avoid  passing  the  expired  air  through 
the  mouth  ;  carbonic  acid  rapidly  changes  the  lime-water  into 
inert  carbonate  of  lime.  Inhalations  are  made  by  placing  the 
medicine  in  an  atomizing  apparatus.      This  procedure  has  one 


428  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

serious  inconvenience.  The  condition  of  extreme  division 
in  which  the  lime-water  is  thrown  infinitely  increases  its  con- 
tact with  atmospheric  air,  and  greatly  favors  its  reduction  into 
carbonate  of  lime,  the  action  of  which  is  negative.  Besides,  it 
is  not  always  easy  to  prevail  on  a  child  to  hold  his  mouth  open 
for  the  necessary  length  of  time.  Irrigation  is  a  very  good 
method;  it  is  employed  when  the  first  two  cannot  be  applied; 
it  is  preferable  to  the  second.  An  irrigator  being  filled  with 
lime-water  diluted  with  milk,  as  for  gargling,  the  patient, 
placed  over  a  wash-basin,  inclines  the  head  forwards.  The 
cannula  introduced  into  the  mouth,  directs  upon  the  diseased 
parts  the  entire  contents  of  the  instrument.  It  is  well  to  re- 
peat the  operation  quite  often,  about  every  hour.  Finally,  if 
none  of  these  three  means  is  applicable  it  may  be  necessary  to 
touch  the  false  membranes  with  a  brush  dipped  in  saccharat-e 
of  lime  or  syrup  of  livie.  This  preparation  has  the  advantage 
of  being  stable. 

The  saccharate  is  much  more  active  than  lime-water,  with- 
out being  at  all  caustic,  since  it  contains  a  larger  quantity  of 
lime  than  lime-water,  lO.  (2Y2  5)  of  the  saccharate  containing 
0.25  (5  grs.)  of  lime,  while  the  same  quantity  of  lime-water 
represents  only  O.oi  ('/,;  gr.)  By  its  action  of  insulating  bodies, 
the  excess  of  sugar  contained  in  the  preparation  explains  this 
peculiarity.  It  increases  and  renders  more  durable  the  con- 
tact of  the  medicine  with  the  morbid  products.  Treatment  by 
lime-water  gives  good  local  results  ;  it  is  neither  painful  nor 
disao-reeable  to  the  taste,  and  it  does  not  interfere  with  the  ap- 
petite. It  may  be  classed  with  those  which  combine  the  con- 
ditions required  of  local  treatment. 

2d.  Neutral  Salts.  Chlorate  of  Potassium. — This  remedy  is 
perhaps  the  one  which  has  been  most  used  in  the  treatment  of 
diphtheritic  angina. 

Robert  Thomas,  of  Salisbury  (18 18),  first  proposed  it  for  an- 
gina maligna.  Chaussier  (1819)  extolled  it  in  croup.  After 
having  fallen  for  quite  a  long  time  into  oblivion,  it  was  pre- 
scribed by  Hunt  (1847)  and  by  Babbington  (1853)  in  gangrene 
of  the    mouth,  by    West,  Henoch   (1850),  Herpin,  of   Geneva, 


TREATMENT.  429 

Blache  (1855)  and  Barthez  in  mercurial  stomatitis,  and  in  gan- 
grene of  the  mouth  and  pseudo-membranous  stomatitis,  and  by 
Bergeron  (1855)  in  ulcerous  stomatitis.  From  ulcerous  stoma- 
titis to  diphtheritic  angina  there  is  but  one  step  ;  Blach 
crossed  it  and  tried  the  salts  of  Berthollet  in  this  disease.  But 
this  treatment  was  established  upon  a  scientific  basis  only  after 
the  appearance  of  the  memoir  of  Isambert  (1856).  This  learned 
author  showed  that  this  substance  was  eliminated  partly  by  the 
saliva  ;  that  it  increased  the  flow  of  saliva  and  resulted  in  a  kind 
of  elective  action  upon  the  mucous  membranes  of  the  throat ; 
the  mucous  membrane  is  changed  and  cleansed,  and  the  false 
membranes  separate.  A  general  influence  upon  the  economy 
has  been  ascribed  also  to  the  chlorate  of  potassium,  by  which 
there  is  an  influence  exerted  against  the  reproduction  of  the 
false  membranes.  The  salt  of  Berthollet  is  used  as  a  local  ap- 
plication, as  a  gargle,  8.  to  10.  (2-3.5)  of  the  salt  to  250.  (83)  of 
water;  and  internally,  4.  (i5)  in  125.  (4S)  of  water,  which  is 
taken  in  spoonful  doses  every  hour. 

After  having  been  praised  by  many  authors,  among  whom 
must  be  mentioned  Andre,Thore,  Petit,  Millard,  and  Chavanne, 
and  after  having  been  prescribed  as  a  specific  in  diphtheria, 
chlorate  of  potassium  fell  into  almost  complete  discredit.  It 
deserves  better,  and  may  render  service,  if  one  does  not  re- 
quire of  it  more  than  it  can  perform.  Its  action  is,  in  fact,  real, 
but  feeble  ;  it  is  purely  local.  When  a  concentrated  solution 
of  chlorate  of  potash  is  placed  in  contact  with  the  false  mem- 
branes, it  attacks  them,  but  slowly.  Now,  being  eliminated  by 
the  saliva,  this  compound  is  found  in  permanent  contact  with 
the  exudates  upon  which  it  acts  as  the  solution  does,  with  this 
difference,  that  the  latter  is  concentrated,  while  the  saliva  never 
contains  the  salt  in  strong  proportion.  This  property  of  chlor- 
ate of  potash  of  maintaining  itself  in  permanent  contact  with 
the  pseudo-membranous  products  was  utilized,  but  in  no  case 
could  one  depend  upon  a  rapid  and  energetic  action.  It  may, 
therefore,  give  good  results  in  angina  with  thin  false  mem- 
branes, but  it  remains  without  result  when  the  exudate  is  thick 
and  consistent.     Its  use  should  be   supplemented    by   that    of 


43*^  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

another  agent  more  active,  lime-water  for  example.  In  that 
case  it  does  service, and  so  much  the  better  as  it  is  perfectly  in- 
nocent, being  deprived  of  the  peculiar  action  of  the  alka- 
lies. 

[This  remedy  is  regaining  its  lost  ground  in  Europe,  It  is 
now  used  freely  internally — even  in  saturated  solution.  The 
only  precaution  to  be  especially  observed  is  not  to  give  it  on 
an  empty  stomach. — Seeligmfiller,Grunberg,HacJilcr,  Hullmann, 
J.  Santy.     Am.  Jour.  Obs.,  May,  1885]. 

Chlorate  of  Sodium. — Possessed  of  a  more  energetic  solvent 
power,  as  Barthez  has  shown,  this  remedy  is  employed  like  the 
chlorate  of  potash  ;  the  solubility  being  greater  permits  of  the 
administration  of  larger  doses. 

lodate  of  Potassium. — Demarquay  and  Gustin  proposed  this 
salt  in  the  place  of  chlorate  of  potash.  It  acts  more  promptly 
and  in  a  less  dose — from  0.25  to  I.  (4 — 15  grs.).  A  peculiar 
sensation  of  constriction  of  the  throat  is  produced  when  1.50 
— 2.  (20 — 30  grs.)  are  given. 

3d.  Acids.  Lemon  Juice. — This  remedy  has  been  in  use  for 
a  long  time.  Guersant  and  Blache  used  it  in  mild  cases.  Re- 
villiout  prescribed  it  in  almost  continuous  applications,  about 
every  ten  minutes.  He  used  in  the  beginning  as  much  as  four 
lemons  an  honr,  of  which  the  juice  was  partly  conveyed  to  the 
back  part  of  the  mouth.  When  improvement  appeared  he  di- 
minished gradually  the  dose,  so  as  to  use  not  more  than  three, 
two  or  even  one  lemon  in  an  hour.  To  complete  the  cure, 
from  one  hundred  and  eighty  to  two  hundred  lemons  were 
sometimes  used.  Although,  from  the  admission  of  the  author, 
this  remedy  was  quite  painful,  and  it  was  said  to  have  an  un- 
doubted solvent  action,  yet  it  acts  in  the  same  manner  as  the 
caustics,  and  is  open,  therefore,  to  the  same  objections. 

Dr.  Chatard,  of  Bordeaux,  praises  this  remedy  also,  which, 
however,  he  changes  slightly  by  prescribing  the  gargle  only 
every  half  hour,  and  uses  only  seventy-seven  lemons.  Dr. 
Soule,  of  Bordeaux,  in  1836,  in  this  way  obtained  good  effects 
from  the  local  action  of  lemon  juice.  These  effects  may  be 
obtained   without   danger,   by   using   this   product    ia    weaker 


TREATMENT.  43  I 

doses ;  besides,  it  is  in  this  way  we  generally  proceed  with  the 
lemon  treatment.  Touch  every  half  hour  the  affected  part 
with  a  brush  dipped  in  the  lemon  juice.  Quite  a  number  of 
practitioners  unite  this  treatment  with  the  alkaline.  This  lat- 
ter method  consists  in  alternating  the  gargle  of  eau  d'  Vichy 
with  the  applications  of  the  lemon  juice.  By  whatever  method 
this  treatment  is  applied  the  results  reached  are  not  very  con- 
clusive, which  is  not  surprising  considering  the  slow  and  quite 
feeble  solubility  of  the  false  membranes  in  citric  acid.  Other 
solvents  exist  which  deserve  preference. 

Lactic  Acid. — Suggested  Bricheteau  and  Adrian  it  acts  rap- 
idly upon  the  false  membranes.  This  is,  next  to  lime  water, 
the  most  powerful  re-agent.  These  authors  advocate  its 
use  in  the  form  of  inhalations  according  to  the  following 
formulae : 

Water,         -         -         lOO.  (3  %) 
Lactic  acid       -         -         5.  (i  1/4  5).  As    a   gargle: 
Or, 

Water, 100.  (3  5). 

Lactic  acid,  .  _         _         -         -  5.  (1Y4  5). 

Syrup  of  orange,       -         -         -         -  30-  (i  §). 

Prof.  Steiner  has  used  this  remedy  with  the  atomizer,  fifteen 
to  twenty  drops  in  30.  {}%)  of  distilled  water.  He  has  wit- 
nessed a  preceptible  improvement  after  each  inhalation. 

Dr.  Bruno  Fehrmann  used  it  for  a  year  in  the  service  of 
Prof.  Wunderlich,  at  Leipzig ;  he  used  it  in  the  proportion  of 
one-seventh,  one-tenth,  and  even  to  one-fiftieth  as  a  spray.  He 
thought  he  saw  the  arrest  of  the  process  in  some  grave  cases. 
Kiichenmeister,  on  the  contrary,  claims  that  lactic  acid  has  no 
beneficial  effect,  and  that  it  has  the  inconvenience  of  disgust- 
ing children  and  ulcerating  the  lips  as  well  as  the  mouth. 
Gargles  and  inhalations  may,  indeed,  produce  these  unpleas- 
ant results.  The  best  mode  of  proceeding  appears  to  me  to 
consist  in  touching  the  false  membrane  frequently  with  a  brush 
dipped  in  the  following  mixture  :     Glycerine  60.,  lactic  acid  3. 

Acetic  Acid. — The  vaporization  (spray)  of  solutions  of  acetic 


432  DIPHTHERIA,    CROUP,   AND    TRACH ICOTOMY. 

acid  of  different  degrees  of  strength,  is  said  to  produce  good 
results  at  the  Charity  Hospital,  New  York.  No  definite  re- 
ports (N.  Y.  Med.  Record,  1874,  p.  144)  are  given  in  support  of 
the  assertion. 

4th.  Mercurials. — Red  prcipitate  and  calomel  have  been 
used  in  some  cases  of  pseudo-membranous  affection.  They 
have  been  thrown,  in  the  form  of  powder,  upon  the  diseased 
parts.     The  action  of  these  remedies  is  unimportant. 

5th.  Brojjiine. — Independently  of  its  internal  use,  bromine 
has  been  used  locally.  I  have  already  indicated  its  use  as  a 
gargle  in  a  '/soo  solution  as  being  prescribed  concurrently  with 
its  internal  use.  Dr.  Rapp  paints  the  throat  three  or  four 
times  a  day  with  the  following  solution  : 

^     Bromini, 

Bromidi    potassii  -         -         -     aa  O.50  (772  grs.) 

Aq.  destill.  -  .         .         _        100.  (s'A,  S).  M. 

Dr.  Schiitz,  of  Prague,  had  previously  spoken  highly  of  this 
remedy.  Dr.  Goltwald  also  praises  it  in  the  highest  terms. 
These  preparations  exert  upon  the  false  membranes  a  certain 
solvent  action,  inferior  in  every  respect  to  that  of  lime-water 
and  of  lactic  acid. 

6th.  Glycerine  of  which  the  solvent  properties  have  been  an- 
nounced, has,  really,  no  action. 

Antiseptics. 

These  remedies  are  of  incontestible  value  in  the  local  treat- 
ment of  diphtheria.  They  do  not  claim  so  much  as  the  pre- 
ceding; they  do  not  pretend  to  destroy  or  dissolve  the  false 
membranes;  but  when  the  latter  are  altered,  when  an  abundant 
sero-purulent  ichor,  often  mixed  with  putrefied  blood,  is  dif- 
fused in  the  mouth,  the  absorption  of  these  products  by  the 
digestive  tract  or  by  the  denuded  parts  of  the  buccal  mucous 
membrane,  exposes  the  patient  to  putrid  infection.  It  is  then 
that  antiseptics  are  highly  indicated.  They  should  be  em- 
ployed largely  by  irrigations,  following  the  method  which  I 
have  already  indicated.     The  injections  should  be  frequent  in 


TREATMENT.  433 

order  to  neutralize,  in  the  most  complete  manner,  the  incessant 
production  of  septic  materials.  Labarraque's  solution  and  the 
permanganate  of  potash  have  been  advocated  for  this  purpose. 
Carbolic  acid,  this  highly  reputed  disinfectant,  has  been  em- 
ployed by  several  authors.  Dr.  Rothe,  of  Altenburg,  uses  it 
by  painting  on  an  alcoholic  solution  of  one-fifth. 

^     Tinct.  iodini  -         -         -         -         -  4.  (l  5)- 
Acid,  carbolici. 

AlcohoHs    - aa  8.  (2  5). 

Aq.  destillatae  -         -         -         -         -  40.  (10  5)  M. 

He  thus  obtained  success  in  fifteen  cases. 

Dr.  Schlier  used  it  exclusively  in  thirty-six  cases,  quite 
grave,  either  in  the  one-tenth  solution  used  with  the  brush,  or 
in  one  per  cent,  used  as  a  gargle.  The  mortality  was  one-sixth. 
All  the  deaths  were  among  children  under  4  years  of  age. 

Dr.  Giovanni,  by  applying  a  one  per  cent,  solution  every  quar- 
ter of  an  hour  to  the  affected  parts,  had  but  one  death  in  fifty- 
eight  cases. 

Dr.  Brasch  also  recommends  carbolic  acid  locally  at  the 
same  time  as  the  ferrated  glycerine  internally.  In  adopting 
this  treatment  he  had  not  seen  the  mortality  exceed  20  per 
cent.,  while  in  cauterization  and  mercurialization  it  had  risen 
as  high  as  57  per  cent.  I  dare  not  affirm  that  these  figures  have 
all  the  value  that  their  author  gives  them.  The  conditions  of 
comparison  fail  between  the  two  series  of  cases.  They  are  in 
every  respect  quite  probable  and  worthy  of  attention.  Dr.  Cal- 
ligari  has  also  obtained  from  it  good  results.  Several  of  the 
authors  whom  I  have  cited  are  satisfied  to  employ  the  carbolic 
acid  by  painting  it  on.  There  is  decided  benefit  in  prescribing 
gargles  or  frequent  irrigations  with  the  one    per  cent,  solution. 

Cliloral. — Since  the  antiseptic  properties  of  chloral  have 
been  demonstrated,  it  has  been  suggested  to  use  it  in  diph- 
theria. 

Dr.  Accetella,  (1873)  considering  diphtheria  as  a  parasitic 
disease,  treats  it  by  painting  four  times  a  day  upon  the  dis- 
eased mucous  membranes  the  following   solution:       Chloral  i. 


434  DIPHTHERIA,     CROUP    AND    TRACHEOTOMY. 

(15  grs.),  distilled  water,  5.   (75    gtt.).     gargles  with  a  solution 
of  one  part  to  23  of  water  are  used  for  adults. 

Marc  See,  (1875)  has  quite  recently  extolled  the  use  of 
chloral  in  diphtheria  of  the  vulva.  This  local  application,  used 
by  him  at  the  suggestion  of  Bergeron,  has  given  him  the  best 
results.  The  preparation  used  is  a  one  per  cent,  solution. 
These  facts  should  encourage  the  general  use  of  chloral  in  all 
cases  of  diphtheria,  and  in  angina  in  particular.  This  compound 
being  antiseptic,  equally  energetic  with  carbolic  acid,  and  of 
more  convenient  application,  one  should  in  all  cases  which 
present  the  indications  for  disinfectants,  employ  chloral  in  one 
per  cent,  solution  as  a  gargle  or  by  irrigations. 

[In  a  recent  work  on  "Diphtheria,  Croup,  etc.,  also  a  delinea- 
tion of  the  new  chloral  hydrate  method  of  treating  the  same, 
and  its  title  to  be  considered  a  specific^'  by  C.  B,  Galentine, 
M.  D.,  Cleveland,  O.,  1884,  the  following  remark  in  the  pre- 
face is  found :  "The  writer  has  been  led,  or  driven,  into  a  new 
and  hitherto  untried  (?)  field  of  therapeutics  in  this  destructive 
disease,  and  for  several  years,  in  the  treatment  of  hundreds  of 
cases  has  demonstrated  to  his  entire  satisfaction  the  claims  of 
chloral  hydrate  to  specific  efficacy  in  the  membranous  diseases, 
diphtheria,  croup,  etc."  Diphtheria  and  croup  are  spoken  of  as 
two  diseases,  but  "  that  its  (chloral  hydrate's)  therapeutic  effi- 
cacy in  croup  is  believed  to  be  as  rational  and  as  well  estab- 
lished as  in  that  (diphtheria)  disease."  "  To  assure  its  greatest 
efficiency,  it  should  not  only  be  given  early  in  the  disease,  but 
should  be  given  freely  and  persistently,  To  a  patient  two  or 
three  years  old  either  of  the  formulae  (23  or  24)  may  be  em- 
ployed in  appropriate  doses  every  hour  or  oftener  when  awake. 
The  following  are  the  formulae : 

B«     Chloral,  hydrat. 

Potass,  chlorat.         _         -         -  aa  40  grs.  (3.20; 
Spts.  gaulth.  vel. 

Spts.  menth.  pip.     -         -         -  i  5  (4.00) 

Syrup,  simpl,,  aq.  -         -         -  aa  2  5  (64.00). 
M.     Dose,  a  teaspoonful  or  a  teaspoonful  and   a  half  every 

hour,  when  awake,  to  a  child  from  5  to  10  years  old. 


TREATMENT.  435 

J^     Chloral,  hydrat, 

Brom.  ammon.     -         -         -       -     aa  70  grs.  (5.00). 

Spts.  chloroform.  -         -       -     1-2  3  (4-to  8.) 

Syrup,  simpl. 

Aquae  -         -         -         -       -     aa  2  5  (64.00). 

M.     Dose,  for  an  adult,  two  teaspoonfuls  every  hour. 

It  is  used  also  as  a  local  remedy.] 

Salicylic  acid. — The  German  school,  persuaded  of  the  para 
sitic  nature  of  diphtheria,  applies  in  this  disease  all  the  para- 
sitical agents.  With  this  view,  salicylic  acid,  vaunted  at  this 
time  as  antiparasitic  and  powerfully  disinfectant,  has  been  used 
by  Wagner  and  Fontheim.  The  latter  used  a  one  per  cent, 
aqueous  solution  as  a  gargle,  and  by  painting  it  on. 

[Dr.  Bedford  Brown,  of  Alexandria,  Va.,  recently  in  a  report  on  the  treatment  of 
diphtheria  recommended  highly  the  following  local  application  : 

Listerinei         --- i6.  ('/■■/|) 

Aq.  cinnamomi,  .-_-_--  128.     (4!^) 

Liq.  sod.  chlorinat.e,        -------  16.  ('/2§) 

Acid  carbol. gtt-  6. 

M      To  be  applied  to  the  nose  and  throat  by  means    of  the  syringe  or   atomizer. 

In  the  hsemorrhagic  variety  he  uses  oil  of  turpentine,  ergot    and  digitalis  internally; 

and  as  a  spray,  a  dilute  form  of  Monsel's  solution. 

'Listerine  is  prepared  by  a  pharmacal  company  in  St  Louis,  and  is,  according  to 
formula  composed  of  the  essential  constituents  of  thyme,  eucalyptus,  baptisia,  gaul- 
theria  and  mentha  arvensis,  together  with  refined  benzo-boracic  acid.] 

Emetics, — These,  with  cauterization,  form  the  classic  treat- 
ment of  diphtheria.  Without  taking  the  emetic  in  contra- 
stimulant  doses,  many  physicians  prescribe  one  or  more  emet- 
ics. It  seems  as  though  the  treatment  would  be  regarded  as  in- 
complete without  these  means.  One  counts  upon  their  me- 
chanical action  to  clear  the  throat  of  false  membranes.  It  is 
for  this  reason  that  I  have  placed  this  method  of  treatment  by 
the  side  of  those  which  exert  direct  effects  upon  the  false  mem- 
branes. By  admitting  that  this  mode  of  action  may  indeed  be 
beneficial,  which  is  doubtful  since  the  false  membrane  which 
separates  is  replaced  by  another,  at  least  that  the  process  itself 
is  not  arrested,  by  admitting,  I  say,  this  principle,  two  points 
present  themselves,  viz.,  the  false  membrane  adheres  firmly,  or 
it  is  in  process  of  separating.     In  the  first,  the    emetic    is    cer- 


436  DIPHTHERIA,  CROUP  AND  TRACHEOTOMY. 

tainly  insufficient ;  in  the  second  it  is  useless.  Why  make  the 
patient  vomit  when  it  is  so  easy  to  complete  the  work  com- 
menced by  seizing  the  false  membrane  with  the  forceps.  One 
spares  the  patient  the  unavoidable  fatigue  of  vomiting  (a  mat- 
ter which  is  worthy  of  being  taken  into  consideration  in  the 
case  of  diphtheria),  as  well  as  the  diarrhoea,  often  very  free, 
which  is  the  consequence  of  it.  For  these  reasons  Barthez  has 
for  a  long  time,  in  such  cases,  renounced  the  emetic  treat- 
ment. 

Conclusion. — It  may  be  seen  from  this  review  that  local 
modifiers  in  the  treatment  of  diphtheritic  angina  are  not  want- 
ing. If  the  disease  was  purely  local,  one  would  find,  without 
difficulty,  in  this  therapeutic  list,  some  means  to  master  it. 
However,  all  are  not  equally  good.  Some,  as  cauterizations, 
are  dangerous  and  worse  than  the  disease.  Others,  more  mild, 
are  not  always  efficacious,  and  if  they  have  an  action  suffi- 
ciently marked  upon  the  thin,  semi-transparent,  soft  false  mem- 
branes, they  effect  but  little  those  which  are  thick,  opaque, 
and  hard.  Moreover,  it  is  necessary,  in  order  that  their  action 
be  manifest,  that  their  contact  with  the  exudate  be  sufficiently 
prolonged.  Now,  this  condition  is  not  always  easy  to  fulfil. 
But  even  when  thus  favored,  one  succeeds  in  attacking  the 
exudate,  thinning  and  dissolving  it,  he  has  not  succeeded  in 
preventing  the  one  which  he  separated  from  being  replaced  by 
another  ;  neither  has  he  prevented  the  extension  of  the  disease  ; 
he  has  only  applied  himself  to  the  products  while  the  disease 
itself  was  inaccessible.  One  no  more  cures  diphtheria  by  de- 
stroying the  false  membranes  than  he  cures  small-pox  by 
aborting  the  pustules.  Therefore,  we  must  recognize  the  fact 
that  while  the  various  local  remedies,  recommended  in  diph- 
theria, result  in  permitting  the  mild  cases  to  recover,  they  do 
not  prevent  the  grave  ones  from  terminating  fatally.  None  ot 
these  means  possess  the  power  of  limiting  the  diphtheritic  pro- 
cess to  the  pharynx,  and  consequently  of  preventing  croup  ; 
no  more  can  any  of  them  boast  of  being  an  obstacle  to  general 
poisoning.  Their  use  should  be  reserved  for  the  cases  in  which 
the  false  membrane   itself,  constituting  a  danger  by   the   mere 


TREATMENT.  437 

fact  of  its  situation,  in  croup,  for  example,  should  be  promptly 
destroyed.  In  angina  there  is  nothing  similar,  the  danger  is 
not  in  the  false  membrane  itself  but  in  the  disease  which  pro- 
duces it  and  which  poisons  the  economy  at  the  same  time  that 
it  provokes  the  fibrinous  exudates.  No  rational  indication  de- 
mands, therefore,  a  destructive  action  of  the  false  membranes. 
The  antiseptics  are  an  exception  to  this  rule,  and  they  may 
find,  under  certain  circumstances,  a  useful  application. 

Resume.  Benign  Diphtheritic  Angina. — The  indications  are 
not  numerous  either  on  the  part  of  the  general  or  of  the  local 
condition.  Gargles  of  lime-water  diluted  with  one  third  of 
milk  may  be  recommended.  In  young  children  we  practice 
penciling  with  the  saccharate  of  lime  or  with  a  mixture  of  lactic 
acid  in  glycerine,  one  to  twenty.  If  the  child  refuses  this 
treatment,  it  is  better  not  to  insist.  If  the  disease  is  really  be- 
nign it  recovers  itself;  if  it  should  become  grave  that  is  not 
the  local  treatment  which  will  prevent  it.  Energetic  means, 
such  as  cauterization,  result  only  in  extending  the  evil ;  the  re- 
sistance which  one  meets  on  the  part  of  the  patient,  and  the 
suffering  which  these  applications  produce,  are  positively  in- 
jurious. 

The  internal  anti-diphtheritic  treatment  is  useless,  especially 
under  these  circumstances.  The  general  condition  should  be 
carefully  observed.  Food  should  be  recommended,  even  re- 
quired ;  liquid  food  or  of  a  soft  consistency  should  be  given 
by  preference  because  of  the  difficulty  of  swallowing.  We 
should  insist  upon  the  use  of  wine  or  beer,  or  coffee  and  qui- 
nine. 

Infections  Diphtheritic  Angina. — The  local  indications,  even 
though  secondary,  should  be  taken  into  consideration.  The 
abundance  of  the  false  membranes  may  be  such  as  to  become 
an  additional  obstacle  to  deglutition ;  their  alteration  and  the 
gangrene  of  the  diseased  parts  give  rise  to  an  ichorous,  san- 
guinolent  oozing,  the  absorption  of  which  may  become  the  cause 
of  septicaemic  infection. 

In  the  beginning,  the  treatment  is  the  same  as  in  the  benign 
form. 

When  the  thickness    and    extent  of   the    false    membranes, 


438  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

added  to  the  adenitis,  shall  have  shown  the  infectious  form,  we 
should  give  internally,  in  addition,  a  solution  containing  4. 
(i  5)  of  chlorate  of  potassium,  or  6  drops  of  bromine  and  0.50 
(8  grs.)  ofbromide  of  potassium.  Aside  from  the  solvent 
action  that  they  may  have,  these  preparations  have  the  prop- 
erty of  being  eliminated  by  the  buccal  mucous  membrane  and 
the  saliva  ;  finally  they  possess  the  advantage  of  bringing  in- 
cessantly into  contact  with  the  diseased  surfaces  a  product 
which  may  modify  and  disinfect  them.  The  alternating  insuffla- 
tions of  alum  and  tannin,  and  of  flowers  of  sulphur,  the  inhal- 
ation of  tannin,  lime-water  and  lactic  acid  will  also  find  their 
indications. 

If  the  false  membranes  are  very  thick  and  obstruct  the  isth- 
mus fauciiim,  one  removes  them  in  whole  or  in  part  with  the 
aid  of  the  forceps.  When  they  are  altered,  when  the  tissues,  mor- 
tified or  not,  exhale  a  fetid  odor,  it  is  necessary  to  have  re- 
course to  irrigations.  They  constitute  the  best  local  treat- 
ment ;  they  wash  the  diseased  parts  even  in  the  most  distant 
recesses.  They  should  be  used  according  to  the  method  indi- 
cated above,  six  or  seven  times  a  day,  and  more  frequently 
still  if  the  patient  will  permit  it.  A  one  per  cent,  solution  of 
carbolic  acid,  chloral  or  salicylic  acid  should  be  used.  In  case 
of  diphtheritic  coryza  irrigations  of  the  nose  should  be  prac- 
ticed also. 

The  treatment  of  complications  will  be  indicated  hereafter. 
The  general  treatment  should  be  provided  for.  Nourishment 
is  more  necessary  than  ever  ;  the  taste  of  the  child  should  be 
indulged,  and  if  the  object  is  not  obtained  by  persuasion,  re- 
course should  be  had  to  intimidation.  Wine  freely  given, 
quinine  in  doses  of  4.  (i  5)  of  the  extract  in  an  infusion  of  cof- 
fee are  of  the  highest  necessity.  Still  the  quinine  may  be  ad- 
ministered in  the  form  of  a  bolus  of  the  extract  containing  i. 
(15  grs.)  each,  which  is  dissolved  in  a  cup  of  strong  coffee 
(without  milk)  at  the  proper  time.  These  means,  very  useful 
in  combating  the  infectious  condition,  should  be  aided  by  the 
internal  administration  of  salicylic  acid  at  the  rate  of  2.  (30 
grs.)  a  day. 

Collapse  and  adynamia  demand  cold  lotions. 


TREATMENT.  439 

Malignant  Angina. — If  the  malignity  is  secondary  the  treat- 
ment should  be  commenced  as  in  the  preceding  form.  For  the 
malignity  itself,  tonics,  alcoholics,  Spanish  wines,  sweetened 
spirits  (grog)  and  cold  lotions  are  the  only  means  of  safety. 
The  malignity  which  is  primarily  manifested,  is  only  amena- 
ble to  the  supporting  and  stimulant  treatment,  the  local  lesions 
being  often  insignificant  in  this  case. 

§  2. — Croup, 

The  present  chapter  takes  the  treatment  from  the  moment 
at  which  the  false  membranes  invade  the  larynx,  whether  the 
croup  is  announced  primarily  or  consecutively  to  an  angina. 
Asphyxia  of  various  degrees  being  nearly  always  the  fatal 
termination  of  croup,  therapeutic  efforts  should  tend  to  pre- 
vent this  dreaded  symptom,  or  to  arrest  it  when  it  is  produced. 
Medical  and  surgical  means  have  been  put  in  operation  to  ful- 
fill these  two  indications. 

Medical  treatment. — Can  croup  be  prevented  ?  Cauterizations 
and  the  local  applications  recommended  with  the  object  of 
preventing  the  propagation  of  the  diphtheritic  process  from 
the  pharynx  to  the  larynx  are  unable  to  prevent  the  invasion. 
We  proved  that  violent  means  result  most  clearly  in  diminish- 
ing the  strength  of  the  patient,  and  in  rendering  alimentation 
still  more  difficult.  We  may  also  demand  whether,  contrary 
to  their  purpose,  they  do  not  result,  by  denuding  and  irritating 
the  healthy  parts,  in  favoring  the  extension  of  the  disease. 
From  the  appearance  of  the  first  symptoms  of  croup  we  should 
begin  the  battle.  A  material  obstacle  obstructs  the  respira- 
tion;  it  should  be  surmounted.  This  is  the  principal  indica- 
tion. In  angina,  the  disease  is  everything,  the  false  mem- 
brane is  nothing  or  almost  nothing  ;  in  croup,  on  the  contrary, 
the  laryngeal  exudate  takes  first  rank,  at  least  for  the  moment. 
This  it  is  which  is  about  to  produce  asphyxia,and  we  should  re- 
move it.  Medication  thus  understood  does  not  reach  the  bot- 
tom, it  attacks  the  lesion  only.  The  obstacle  when  removed 
may  be  reformed ;  that  is  true.  But  the  cases  in  which  croup 
has  recovered  after  a  single  expulsion  of  false  membranes  are 


440  DIPHTHERIA,     CROUP    AND    TRACHEOTOMY. 

not  rare  ;  if  the  obstruction  should  reform,  one  will  always 
have  gained  time;  he  may  hope  to  reach  a  time  when,  the 
process  being  exhausted,  the  production  of  false  membranes 
will  cease.  The  most  urgent  treatment,  therefore,  is  that 
which  is  directly  addressed  to  the  false  membrane.  Several 
systems  have  been  put  into  practice  with  the  object  of  remov- 
ing the  laryngeal  obstruction.  They  all  consist,  either  in  de- 
stroying the  false  membrane  by  local  changes,  or  by  expelling 
it  by  means  of  sudden  shocks  (secousses)  impressed  upon  the 
respiratory  tract. 

For  a  certain  time  at  the  beginning  of  the  disease,  blisters 
to  the  front  part  of  the  neck  have  been  prescribed,  with  the 
hope  of  overcoming  the  exudative  inflammation  and  arresting 
the  pseudo-membranous  production.  These  means  have  no 
beneficial  influence,  but  to  the  contrary. 

The  irritated  skin  becomes  covered,  most  frequently,  with 
diphtheritic  concretions.  If  the  patient  should  be  submitted 
to  tracheotomy,  the  blister  causes  much  difficulty  in  the  per- 
formance of  the  operation.  The  tumefied  and  indurated  tis- 
sues conceal  the  situation  of  the  trachea;  the  land-marks  be- 
come inappreciable,  and  the  skin  thus  made  slipper>-,  offers  no 
hold  for  the  fingers.  In  short,  the  conditions  are  the  most  un- 
favorable under  which  the  operation  can  be  performed. 

Local  Modifiers. 

We  shall  again  meet  all  the  modifiers  proposed  in  angina, 
but  as  in  croup  the  false  membranes  are  not  accessible  to  gar- 
gles, to  penciling  nor  to  insufflations,  it  becomes  necessary 
to  seek  some  special  means  to  convey  the  remedy  as  far  as  the 
larynx.  These  are  fumigations,  inhalations  and  catheterism 
of  the  larynx. 

Fumigations  constitute  the  most  natural  method  of  bringing 
the  remedies  in  contact  with  the  respiratory  mucous  mem- 
brane. Every  volatile  substance  is  conveyed  by  inspired  air, 
and  easily  reaches  its  destination. 

The  method  most  in  use  consists  in  placing  by    the    bedside 


TREATMENT.  44-1 

of  the  patient  an  apparatus  in  which  water  may  be  maintained 
in  a  state  of  ebullition  during  the  entire  time  necessary.  The 
substance,  of  which  we  desire  the  therapeutic  action,  is  added 
to  the  water.  A  sheet  arranged  around  the  bed  prevents  the 
diffusion  of  the  vapors  ;  those  which  emanate  from  the  remedy, 
conveyed  by  those  which  arise  from  the  water,  form  around 
the  patient  an  artificial  atmosphere, which  is  brought  in  constant 
contact  with  the  air-passages. 

The  vapors  of  pure  water  or  charged  with  emollient  plants, 
were  at  first  employed,  and  this  practice  enjoyed  a  great  run. 
Much  was  hoped  from  the  prolonged  bath  of  the  respiratory 
mucous  membrane  which  resulted  from  it.  This  is  a  rational 
means,  but  I  do  not  believe  that  it  ever  prevented  the  develop- 
ment of  the  false  membranes.  Its  true  indication  is  found  in 
stridulous  laryngitis.  Search  also  has  been  made  for  substan- 
ces the  vapors  of  which  might  have  a  direct  action  upon  the 
false  membrane.  However,  amongst  English  physicians,  the 
tent  for  inhalations  still  remains  in  favor. 

Fumigations  of  cEther,  recommended  at  the  beginning  of 
the  present  century  by  Pinel  and  Alibert,  have  been  brought 
again  to  light  by  Dr.  Bisson.  It  is  reported  to  have  produced 
good  effects  ;  in  two  cases  of  croup  it  is  said  to  have  aided  in 
throwing  off  the  false  membranes.  These  cases  are  too  few  to 
enable  the  method  to  be  judged  of;  besides,  the  use  of  the 
aether  came  in  only  after  several  other  plans  of  treatment.  Its 
action,  it  seems,  is  supposed  to  attack  the  spasmodic  condition 
of  the  muscles  of  the  larynx  rather  than  the  pseudo-membran- 
ous productions  themselves. 

Iodine  fiiniigations. — Being  recommended  by  Warring  Cur- 
ran,  it  is  used  in  the  following  formula : 

^     lodini. 

Potass,  iodidi,  aa         -         -         -         0.20  (3  grs.) 

Alcohol,         -  -         -         -  12.  (30) 

Aquae,        -         -         -         -         -     120.  (4§) 

Add  to  this  mixture  half  a  litre  (pint)  of  vinegar  and  a  hand- 


442  DIPHTHERIA,  CROUP    AND  TRACHEOTOMY. 

fulofsage.  Take  daily  as  high  as  a  dozen  inhalations  of 
twelve  minutes  each  for  an  adult.  The  dose  of  iodine  should 
be  rapidly  increased  according  to  the  tolerance  of  the  patient 
and  other  indications.  In  order  to  simplify  the  application  of 
this  process,  the  author  recommends  placing  the  mixture  in  a 
teapot,  and  breathing  the  vapor  from  the  spout.  A  certain 
number  of  recoveries  are  said  to  have  been  the  result  of  this 
method.  It  is  to  be  feared,  however,  that  the  irritant  action 
of  the  vapor  of  iodine  might  produce  upon  the  respiratory 
tract  injurious  effects  for  which  the  theoretical  advantage  of  the 
remedy  would  not  compensate.  This  charge  may  be  made  in 
a  general  way  against  all  irritating  substances  which  are  intro- 
duced into  the  respiratory  tract.  Should  they  be  sufficiently 
diluted  to  be  harmless,  they  lose  their  local  action.  Should 
they  be  sufficiently  concentrated  they  irritate  decidedly  the 
lungs  and  become  an  active  cause  of  pneumonia.  This  result 
is  less  to  be  feared  with  pulverizations  (atomizations)  which 
carry  into  the  bronchi  a  homogeneous  powder,  while  the  fumi- 
gations carry  mainly  volatile  substances ;  these  reaching  the 
pulmonary  mucous  membrane  almost  in  a  pure  state  cauterize 
it.  I  shall  place  in  the  same  category  bromine  fumigations 
recommended  by  Ozanam. 

Fumigations  with  sulphnret  of  mercury. — This  system  was 
conceived  with  the  object  of  utilizing  the  solvent  action  which 
mercury  exercises  upon  diphtheritic  false  membranes.  Abeille 
placed  at  the  foot  of  the  patient's  bed  a  wide-mouthed  earthen 
vessel  in  which  he  kept,  at  the  boiling  point,  water  charged 
with  emollient  plants,  viz.,  mallow,  violets,  poppies,  and  into 
which  was  thrown,  every  three  hours,  2.  ('/sO)  of  cinnabar. 

In  nine  cases  of  croup  nine  recoveries  are  said  to  have  been 
obtained,  and  yet  this  treatment  was  seen  to  stop  in  the  run  of 
its  recoveries !  It  has  been  proved,  in  fact,  that  cinnabar  does 
not  emit  vapors  at  the  temperature  of  boiling  water,  but  that 
it  decomposes  and  eliminates  sulphuretted  hydrogen.  The  ap- 
paratus, therefore,  furnishes  simply  vapor  of  water  more  or  less 
charged  with  sulphuretted  hydrogen,  but  none  of  the  mer- 
cury. 


TREATMENT.  443 

[NEW  SPECIFIC  TREATMENT  OF  DIPHTHERIA. 

By  Dr.  Dei/fhil. 

Presented  to  the  Academy  of  Medicine,  Paris,  March  25,  1884,  a  dissertation  in 
which  he  extols  the  use  of  fumigations  of  coal-tar  and  turpentine  in  the  treatment  of 
diphtheria.  The  conclusions  of  the  memoir,  in  brief,  are  as  follows;  (Ann.  des  Mai. 
de  I'ortille,  der  larynx,  etc.,  Mai,  18S4. 

1.  The  combustion,  in  the  middle  of  the  sick  chamber,  of  a  mixture  of  coal-tar 
(goudron  de  gaz)  and  of  turpeniine  in  the  proportion  of  about  200.  of  the  former  to 
60.  of  the  essence  of  tuipentine  (lo  to  3)  or  even  turpentine  alone,  renewed  every  two 
or  three  hours,  according  to  the  gravity  of  the  case,  and  at  intervals  according 
to  the  amelioration  produced,  is  a  specific  medication  in  the  treatment  of  diph- 
theria. 

2.  These  fumigations  are  entirely  inoffensive  of  themselves ;  they  are  easily 
borne  by  the  patient,  and  by  the  attendants,  and  they  do  not  excite  coughing. 

The  amount  may  be  varied  considerably  according  to  the  indications  and  especially 
according  to  the  size  of  the  room  occupied  by  the  patient.  I  again  repeat  that  Nor- 
wegian tar  must  not  be  used. 

3.  These  anti-diphtheritic  fumigations  have  for  the  false  membranes  disintegrating 
properties  of  a  high  order. 

4.  At  the  onset  of  the  affection,  they  rapidly  arrest  the  disease. 

5.  In  a  case  in  which  the  physician  is  called  too  late,  they  render  eminently  prac- 
tical the  operation  of  tracheotomy  when  this  latter  becomes  the  last  resort ;  they 
transform  this  operation,  palliative,  expectant,  and  doubtful  as  it  is  in  the  immense 
majority  of  cases,  into  one  with  a  well  defined  object ;  they  favor  success. 

6.  These  fumigations  are  prophylactic,  protecting  the  attendants  who  wait  on  the 
p.itients;  and  by  their  microbicide  or  parasiticide  and  disinfectant  properties,  they  re- 
move the  danger  of  contagion. 

7.  They  may,  therefore,  further  be  used  to  purify  school-rooms,wards,  public  build- 
ings and  hospitals. 

8.  Finally,  this  mode  of  treatment  is  recommended  by  its  great  simplicity,  it  can 
lie  applied  eveiywhere,  and  from  the  outset  of  the  affection;  in  hospitals  it  will  be 
easy  to  establish  a  room  for  fumigation.  I  shall  conclude  this  communication  by 
snyjig  that  I  think  the  essence  of  turpentine  alone  or  in  combustion  will  probably 
s  .nice.] 

Inhalations. — This  method  consists  in  making  the  patient  in- 
hale vapors  of  volatile  substances  at  an  ordinary  temperature, 
or  liquids  reduced  by  the  atomizer  to  a  condition  analogous  to 
that  of  vapor.  The  vapors  of  hydrochloric  acid  were  employed 
by  Bretonneau.  Being  partial  to  the  action  of  hydrochloric 
acid  upon  false  membranes  of  the  throat,  the  physician  of  Tours 
thought  that  the  vapors  of  this  same  product,  conveyed  into 
the  air-passages,  might  have  a  similar  effect  upon  the  laryngeal 


444  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

false  membranes.  But  this  violent  means,  the  irritant  action 
of  which  could  only  favor  the  extension  of  the  pseudo-mem- 
branous process  and  the  development  of  pneumonia,  has  fallen 
into  meiited  neglect  in  spite  of  the  ability  which  Homolle  has 
displayed  to  rescue  it. 

Inhalations  of  Ammonia  recommended  by  Daguillon,  of 
Oran,  are  practiced  by  means  of  a  sponge  dipped  into  ammonia 
and  tied  to  a  slender  holder,  and  after  being  sufficiently  pressed 
to  free  it  of  the  excess  of  the  liquid,  it  is  passed  between  the 
tonsils  without  touching  them.  The  heat  of  the  region  facili- 
tates the  evaporation  of  the  ammonia  ;  and  the  child  is  allowed 
to  breath  as  long  as  he  does  not  experience  too  much  incon- 
venience. The  operation  is  repeated  three  times  in  two  hours. 
It  is  irnportant  to  follow  it  with  washes,  gargles  and  a  drink  of 
fresh  water.  At  the  same  time  the  patient  takes  sulphuret  of 
antimony,  chlorate  of  potassium,  and  emetics;  revulsives  and 
discutients  are  applied  to  the  neck.  This  treatment  appears 
to  me  nearly  as  dangerous  as  the  preceding  and  as  every  other 
which  introduces  irritant  substances  into  the   bronchial    tubes. 

Pulverizations.  Atomizing. — Barthez  had  the  idea  of  apply- 
ing in  croup  the  ingenious  system  invented  by  Sales-Girons  for 
the  treatment  of  chronic  diseases  of  the  air-passages.  A  solu- 
tion of  tannin,  one  twentieth,  or  rarely  one  tenth,  is  the  solu- 
tion used  on  this  principle.  The  inhalations  should  be  quite 
frequent,  and  should  continue  fifteen  or  twent)'  minutes  each 
time.  The  results  obtained  have  been  favorable.  In  the  throat 
the  false  membranes  are  changed  quite  rapidly,  and  they  be- 
come indurated,  and  as  it  were,  tanned.  In  certain  cases  it 
was  possible  to  obtain  this  action  at  the  end  of  twenty-four 
hours. 

In  patients  attacked  with  croup  the  curative  effect  is  mani- 
fest by  the  calming  of  the  dyspnoea,  and  the  disappearance  of 
the  attacks  of  suffocation.  We  have  been  able  to  find  the  air- 
passages  absolutely  clear,  even  when  the  diphtheritic  poison- 
ing has  produced  death.  Other  substances  have  served  for 
inhalations,  among  them  the  perchloride  of  iron,  lime-water 
and  lactic  acid.      Steiner  has  used   lime-water   and   lactic   acid 


TREATMENT.  445 

largely;  he  speaks  highly  of  their  effects.  Kiichenmeister, 
on  the  contrary,  asserts  that  lactic  acid  has  no  beneficial 
action,  ulcerates  the  lips  and  disgusts  the  children. 

The  solution  of  bromine,  i  to  500,  may  also  be  employed  by 
inhalation. 

It  may  be  seen  that  there  is  not  yet  an  agreement  upon  this 
point  in  therapeutics.  In  the  meantime  atomizations  having, 
in  general,  no  inconvenience,  they  may  always  be  employed;  we 
can  obtain  benefit  from  them  in  more  than  one  case.  The  age 
of  the  children  appears  to  me  to  have  much  influence  in  the 
difference  of  the  results  obtained. 

The  atoms  of  water  penetrate  the  air-passages  so  much  far- 
ther when  the  patient  submits  readily.  If  we  may  admit, 
strictly  speaking,  though  the  fact  has  been  denied,  the  en- 
trance of  these  preparations  in  the  larynx  in  an  atomized 
state,  after  having  passed  the  nasal  fossae,  it  is  plain  that  the 
operation  will  give  more  definite  results  in  a  patient  who  would 
open  the  mouth  largely  and  inspire  strongly. 

In  admitting  that  a  part  of  the  spray  is  condensed  along  the 
soft  palate,  we  may  acknowledge  that  a  certain  quantity  pen- 
etrates the  larynx.  Children  old  enough  to  be  reasonable,  and 
adults,  are,  therefore,  the  only  ones  properly  adapted  to  the 
operation  ;  one  should  explain  the  details  to  them  and  advise 
them  to  elevate  the  soft  palate  as  much  as  possible.  The  so- 
lution of  tannin,  one  part  to  twenty,  lactic  acid  in  the  same 
proportion,  and  lime-water,  appear  to  be  the  substances  ofler- 
ing  the  most  advantage.  Lime-water,  however,  suggests  to 
me  a  certain  reserve. 

Injections  into  the  trachea. — Two  methods  have  been  at- 
tempted for  the  introduction  of  lime-water  into  the  air-pas- 
sages. Dr.  Gottstein  introduced  it  by  the  mouth.  This  method 
was  quickly  abandoned  on  account  of  the  attacks  of  suffoca- 
tion produced  by  it.  Dr.  Albu,  physician  of  the  Saint  Lazare 
Hospital,  Berlin,  conceived  the  idea  of  puncturing  the  trachea 
between  two  rings  with  a  hypodermic  syringe  filled  with  lime- 
water,  and  injecting  the  contents  into  the  trachea.  Six  pa- 
tients had,  following  the  operation,  violent  attacks  of  coughing 
during  which  they  expelled  false  membranes. 


446  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

This  hazardous  attempt  gave  only  moderate  results ;  only 
one  patient  recovered.  It  may  be  remarked  that  the  lime- 
water,  applied  by  this  method,  could  have  no  influence  upon 
the  false  membranes  of  the  larynx  ;  its  action  is  limited  to  the 
trachea  as  in  the  instillations  which  are  made  through  the  can- 
ula  after  the  operation  of  tracheotomy.  These  cases  show  that 
the  injection  had  but  one  result,  that  of  exciting  a  violent 
cough  which  might  facilitate  the  expulsion  of  the  false  mem- 
branes. 

Catheterism  of  the  larynx. — Formerly  reserved  for  oedema- 
tous  laryngitis,  and  to  the  asphyxia  of  the  new  born,  this  op- 
eration has  been  applied  to  croup  by  Loiseau,  of  Montmartre. 
This  physician  introduced  directly  into  the  larynx  caustic  or 
astringent  substances.  He  announced  a  large  number  of  re- 
coveries, the  result  of  several  years'  practice. 

This  communication  created  quite  a  sensation  in  the  med- 
ical world  ;  it  was  tried  on  all  sides.  Large  learned  societies 
entered  the  subject  in  their  order  of  the  day.  The  Acadcuiie 
de  medicine  and  the  Societe  medicale  des  liospitaux  of  Paris, 
caused  the  question  to  be  examined  by  committees. 

Trousseau  was  the  reporter  for  the  first  and  Barthez  for  the 
second.  Laryngeal  catheterism  proposes  to  apply  to  the 
false  membranes  which  line  the  internal  surface  of  this  organ, 
substances  capable  of  modifying  them.  The  principal  instru- 
ment is  a  laryngeal  tube  through  which  one  may  blow  pow- 
ders and  pass  the  probang  carrying  caustics,  sponges,  curettes, 
forceps,  etc.  The  operative  procedure  is  the  following :  the 
first  phalanx  of  the  left  index  finger,  being  guarded  with  a 
metallic  ring  about  an  inch  in  diameter,  this  finger  is  carried 
quickly  to  the  bottom  of  the  pharynx  until  it  encounters  the 
epiglottis  which  it  raises  and  holds  in  this  situation.  The  lar- 
yngeal tube,  held  in  the  right  hand,  is  directed  along  the  left 
index  until  it  enters  the  larynx.  The  whistling  escape  of  air 
through  the  tube  proves  that  this  has  entered  the  air-passage. 
The  following  is  a  resume  of  the  treatment  of  croup  as  pre- 
sented by  Loiseau  : 

1st.  Preventive  treatment  or  in   case  of  membranous    angina 


TRKAIMENT.  447 

the  use  of  tannin    and    of  alum   as    local    applications ;  tonic 
regimen, 

2d.  Membranous  angina  zvith  commencement  of  aphonia  or 
croupal  voice  :  instillations  of  tannin  and  alum  about  the  en- 
trance of  the  glottis  added  to  the  above  treatment. 

3d.  Confiniied  croup,  but  without  the  embarrassment  oj  the 
respiration  :  introduction  of  local  styptics  by  the  aid  of  cathe- 
terism. 

4th.  Confirmed  croup  tvith  commencement  of  asphyxia :  ex- 
traction of  the  false  membranes  by  swabbing  or  scraping,  and, 
above  all,  the  introduction  of  astringents. 

5th.  Permanent  asphyxia,  but  not  yet  threatening  :  endeavor 
to  extract  the  false  membranes,  and  perform  tracheotomy  if 
no  beneficial  change  is  obtained. 

6th.  Manifest  [paraissaut)  asphyxia  presents  imminent  dan- 
ger: perform  tracheotomy  immediately,  but  if  it  is  refused, 
practise  catheterism  as  the  last  resource  and  endeavor  to  ex- 
tract the  false  membranes. 

This  practice  may  be  substituted  for  tracheotomy  only  when 
the  latter  is  refused  or  contra-indicated. 

Local  applications  injected  are,  weak  solutions  of  nitrate  of 
silver,  or  astringent  solutions  of  alum  and  tannin  ;  energetic 
caustics  are  proscribed.  To  the  medicinal  applications  should 
be  added  the  swabbing  or  scraping  of  the  larynx  with  the  dry 
sponge.  All  internal  treatment,  except  quinine,  should  be 
abandoned.  Food  and  wine  are  the  only^  internal  means  ad- 
mitted. 

After  having  proved  that,  in  a  large  number  of  the  cases  re- 
ported by  Loiseau  in  support  of  his  method,  the  diagnosis  was 
very  questionable,  Barthez  studied  the  results  of  this  treat- 
ment. The  operation  is,  generally  speaking,  easy ;  however, 
difficulties  are  encountered  in  very  young  children  of  which 
the  mouth  may  not  always  admit  the  protective  ring,  and  in 
which  the  larynx  is  too  narrow  for  sounding,  Catheterism 
was  nearly  always  well  borne  ;  in  cases,  however,  in  which 
forced  scraping  or  friction  of  the  larynx  has  been  practiced 
with  a  dry  sponge,  the  patient  complained  of  pain.     In  some 


448  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

circumstances  a  sudden  amelioration,  though  transient,  was 
noted  immediately  after  the  operation. 

Cauterization  of  the  larynx  with  nitrate  of  silver  is,  of  all  the 
measures,  that  which  produced  most  frequently  a  momentary 
improvement.  But,  more  commonly,  injections  provoked  fits 
of  coughing  or  attacks  of  suffocation.  Dr.  Costilhes  in  this 
way  lost  one  of  his  patients  ;  such  an  accident  was  near  hap- 
pening to  Peter.  In  a  certain  number  of  cases  the  asphyxia 
continued  to  increase  and  tracheotomy  became  necessary. 
This  aggravation  of  asphyxia  was  sufficiently  frequent  to  cause 
several  physicians  to  take  the  precaution  to  make  every  pre- 
paration for  tracheotomy,  when  a  child  was  to  be  subjected  to 
the  treatment  of  Loiseau.  Spasms  of  the  larynx  and  rolling 
back  of  the  false  membranes  by  the  instrument  appeared  to  be 
the  cause  of  these  accidents. 

It  is  necessary,  also,  to  mention  the  cases  of  pneumonia 
which  were  the  consequence  of  injection  of  the  bronchial 
tubes,  with  astringent  solutions  and  especially  with  caustics. 
In  26  patients  subjected  to  catheterism,  Barthez  witnessed  13 
recoveries  of  which  four  only  could  be  attributed  to  the  treat- 
ment; in  nine  others  it  had  to  be  abandoned,  and  recover}- 
was  due  seven  times  to  tracheotomy,  and  twice  to  internal 
treatment.  This  question  was  recently  studied  in  Germany  by 
Schrotter  and  von  Huttenbrenner.  The  conclusions  of  these 
authors  are  the  same. 

Catheterism  of  the  larynx  may  in  some  cases  produce  good 
results,  but  most  frequently  it  brings  onh'  temporary  allevia- 
tion. It  has  many  disadvantages,  to- wit,  it  may  kill  at  once, 
or  aggravate  the  oppression  and  cause  paroxysms  of  suffoca- 
tion. When  it  is  repeated  frequently  it  is  especially  depress- 
ing to  the  forces.  The  introduction  of  the  wedge  between  the 
teeth  may  injure  the  gums ;  and  also,  the  contact  of  the  instru- 
ments with  the  mucous  membrane  of  the  larynx,  especially 
when  scraping  is  practiced,  may  excoriate  this  membrane ; 
thence  extension  of  the  false  membranes.  The  doubt- 
ful advantages  which  this  method  of  treatment  produces 
are,  therefore,  fully  balanced  by   the   dangers   to  which   it   ex- 


TREATMENT.  449 

poses.  It  is  but  right  that  it  has  fallen  into  desuetude  after 
having  enjoyed  an  ephemeral  notoriety.  In  the  same  list  with 
the  method  of  Loiseau  may  be  placed  the  cauterizations  of  the 
larynx  practiced  by  means  of  a  sponge  dipped  in  a  solution  of 
caustic  and  attached  to  the  end  of  a  curved  whalebone.  This 
treatment  which,  without  having  any  of  the  advantages  of  the 
former,  increases  the  inconveniences  and  adds  others  still  more 
serious,  and  should  be  absolutely  banished  from  the  practice. 
Local  modifiers  after  absorption. — The  chlorate  of  potassium, 
the  balsams  and  the  bromides  have  been  administered  in  croup 
without  very  important  results.  The  chlorate  of  potassium  is 
eliminated  by  the  saliva  and  by  the  buccal  mucous  membrane; 
it  is  without  effect  upon  the  respiratory  passages  ;  its  action  is, 
therefore,  nil  upon  the  laryngeal  false  membranes.  I  have 
shown  how  questionable  was  the  influence  of  the  balsams,  and 
will  not  recur  to  them.  The  bromine  preparations,  being 
eliminated  by  the  air-passages,  may  have  a  modifying  influence 
on  the  mucous  membrane  and  on  the  false  membranes.  With 
that  view  their  use  is  rational.  Is  it  effectual  ?  Experience  is 
not  sufficient  in  this  respect,  but  these  means  deserve  a  more 
extended  trial. 

EMETICS. 

It  is  not  sufficient  to  endeavor  to  destroy  or  to  modify  the 
false  membranes;  when  asphyxia  commences  we  must  endeavor 
to  expel  them  quickly.  The  violent  efforts,  the  energetic  con- 
tractions which  accompany  the  vomiting  facilitate  and  com- 
plete the  separation  of  the  exudates  and  then  expel  them. 
Ancient  as  well  as  modern  authors  recognize  the  benefit  of 
emetics ;  it  is  the  only  medication  which  has  continued  through 
the  ages,  was  employed  differently  according  to  the  theory 
which  prevailed,  and  has  never  been  abandoned. 

The  emetic  method,  properly  speaking,  will  be  a  special 
question ;  the  contra-stimulant  method  has  heretofore  been 
set  forth. 

Tartar  emetic  was  for  a  long  time  the  only  one  in  use.  It  is 
still  given  in  doses  of  O.05  (Vi  gr.)  to  .10  to  .15  (172  gr.to  2  gr.) 
alone  or  combined  A^ith  ipecacuanha.     The  first  dose  is  usually 


450  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

sufficient  to  produce  vomiting ;  the  others  often  excite  diar- 
rhcea  and  depression  of  the  forces.  These  disadvantages  are 
not  always  avoided  even  by  the  small  doses,  especially  in 
children.  Therefore,  it  is  necessary  to  be  very  cautious  with 
tartar  emetic  in  early  age.  It  would  be  better  to  renounce  it 
absolutely.  This  is  the  course  which  I  have  taken  ;  such  is 
also  the  practice  of  Barthez. 

It  is  well,  when  we  have  recourse  to  this  remedy,  to  have 
the  patient  drink  but  little  ;  neglect  of  this  precaution  would 
increase  the  chances  of  intestinal  symptoms. 

Sulphate  of  Copper. — This  remedy  has  been  largely  used.  It 
was  advocated  originally  by  Hoffmann  in  1821,  and  by  Zim- 
mermann,  Droste  and  by  Serlo,  who  appear  to  have  employed 
it  rather  in  stridulous  laryngitis,  and  by  Harless,  Korting,  Diirr 
and  Beringuier.  Prof.  Stoeber,  of  Strasburg,  spoke  of  it  in  the 
highest  terms.  Trousseau  considered  it  the  most  certain  of 
the  emetics.  It  is  given  in  small  doses,  from  0.20,  O.30  to 
0.40  (3  to  6  grs.)  or  more  in  divided  doses.  Notwithstanding 
the  advantages  which  have  been  conceded  to  it^  this  salt  is 
quite  an  energetic  irritant ;  it  provokes  gastric  pains,  and  quite 
frequently  induces  diarrhoea. 

Ipecacuanha. — This  is  the  emetic  which  is  best  suited  for 
children  ;  there  is  less  risk  of  intestinal  complications  with 
it  than  with  any  other. 

Ipecac  may  be  given  in  powder  in  a  dose  of  0.50  to  1. 50, 
(7  to  20  grs.)  mixed  with  a  little  water. 

Other  substances  have  been  recommended  as  emetics,  such 
as  the  sulphate  of  zinc,  senega,  violet  root,  etc.  They  were 
used  only  on  rare  occasions  and  are  now  out  of  use.  To  this 
list  it  is  proper  to  add  a  medicine  recently  discovered — apo- 
morphia.  I  have  not  had  occasion  to  use  it  in  the  case  of 
croup ;  I  know  not  whether  other  physicians  have  tried  it.  It 
possesses  properties  which  appear  to  recommend  it  in  a  very 
special  manner  in  this  disease.  It  is  administered  by  the  hy- 
podermic method  which  avoids  the  resistance  which  children 
so  frequently  make  to  taking  emetics.  It  acts  very  quickly,  in 
from  three  to  five  minutes ;  it  obviates  or  abridges  very  much 


TREATMENT.  451 

the  peroid  of  nausea.  It  often  succeeds  in  cases  where 
other  emetics  have  no  effect.  Therefore,  there  is  ease  of  ad- 
ministration, rapidity  of  action  and  exhaustion  less  decided. 
These  reasons  are  of  much  value.  The  only  obstacle  to  its 
general  introduction  is  its  difficulty  of  preservation.  It  changes 
very  rapidly.  Remedies  to  be  employed  in  croup  should  be 
always  within  reach. 

Whatever  remedy  one  may  make  choice  of,  it  remains  to  be 
understood  at  what  period  of  the  disease  it  should  be  given 
and  in  what  proportion. 

Emetics  have  been  administered  in  all  periods  of  croup.  We 
should  consider,  however,  that  their  action  being  purely  me- 
chanical, they  can  only  have  effect  at  the  moment  when  the 
false  membrane  begins  to  separate;  the  efforts  then  have  the 
effect  of  facilitating  its  separation.  They  have  still  a  useful 
result  in  these  cases  in  which  the  exudate  is  thin,  friable, 
slightly  adherent  and  remain  so.  Now,  it  is  not  in  the  first 
period  that  the  false  membrane  begins  to  be  less  adherent,  so 
that  it  can  be  removed  by  an  effort ;  on  the  other  hand,  if  it 
remains  thin  and  friable,  it  rarely  conducts  the  disease  beyond 
the  first  period.  Hence,  it  is  at  the  beginning  of  the  second, 
at  the  moment  when  asphyxia  commences,  that  emetics  ought 
to  be  administered.  Later,  at  the  third  period,  from  the  fact 
of  diminished  activity  of  absorption,  or  of  anaesthesia  of  the 
gastric  membrane,  they  remain  without  effect. 

In  what  proportion  should  they  be  prescribed  ?  Many  au- 
thors have  held  that  emetics  act  well  only  when  given  fre- 
quently dose  after  dose.  Valleix  and  Bouchut  have  made  them- 
selves particularly  the  champions  of  this  method.  Some  fortu- 
nate series  have  been  reported  in  its  support,  However,this  sys- 
tem has  disadvantages  greater  than  its  advantages.  Under  the 
influence  of  repeated  emetics  we  see  the  patients  grow  pale, 
become  depressed,  and  refuse  food;  in  spite  of  all  the  prcautions 
uncontrollable  vomiting  and  obstinate  diarrhoea  supervene. 

Tracheotomy,  to  which  we  nearly  always  come,  at  last,  how 
will  it  be  borne  by  a  patient  reduced  to  such  a  state  of  de- 
pression ?     In  this  respect  I  support    my    opinion    by    that    of 


452  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

two  physicians  of  great  distinction,  Trousseau  and  Barthez, 
who  have  shown  in  many  cases  the  fatal  effects  of  repeated 
emetics  upon  the  results  of  tracheotomy.  These  two  masters 
have  positively  affirmed  that,  in  cases  of  equal  intensity,  the 
results  of  tracheotomy  are  so  much  the  more  favorable  in  pro- 
portion as  the  patients  have  been  less  tormented  by  previous 
medical  treatment. 

Repeated  emetics  have  other  dangers.  It  is  not  rare  that 
the  attacks  of  suffocation  supervene  while  the  patient  finds  him- 
self under  the  influence  of  the  emetic  ;  death  may  be  the  re- 
sult of  such  an  accident.  There  is,  finally,  a  more  frequent  ac- 
cident than  is  generally  believed.  When  one  is  lavish  with 
emetics  in  all  the  periods  of  croup,  the  third  having  arrived, 
the  economy  no  longer  responds  to  these  remedies ;  I  have  in- 
dicated the  reason  of  it.  The  emetic  remaining  without  ef- 
fect another  is  given  with  the  hope  of  seeing  it  act,  and  some- 
times several  afterwards  with  no  better  results. 

Tracheotomy  is  performed,  asphyxia  is  removed,  anaesthesia 
disappears,  and  absorption  is  resumed.  The  emetics  which 
have  accumulated  during  the  period  of  asphyxia  begin  then 
to  act  •  thence  general  breaking  down,  prostration  and  symp- 
toms of  great  gravity  which  compromise  the  success  of  the  op- 
eration. 

Emetics,  are,  therefore,  useful,  but  only  when  given  at  a 
proper  time,  about  the  commencement  of  the  second  period, 
and  wisely  managed.  I  do  not  pretend  that  one  should  always 
limit  himself  to  a  single  trial.  If  the  first  is  well  borne,  and 
the  indications  are  decided,  nothing  prevents  the  repetition. 
Dr.  Fleischmann  has  recently  produced  statistics  of  a  kind  to 
show  that  this  method  of  treatment  has  not  always  the  advan- 
tao-es  which  have  been  attributed  to  it.  Of  thirty-seven  chil- 
dren treated  from  1863  to  1873  by  emetics  solely,  and  not  m 
tracheotomized,  he  counted  only  three  recoveries. 

Ster)iiitatori€s. — Advocated  by  some  physicians,  the  use  of 
these  remedies  has  fallen  into  oblivion.  It  appears,  a  priori, 
says  Barthez  and  Rilliet,  that  sneezing,  which  is  only  a  sudden 
expiration,  ought  to  be  a  valuable   means   for  favoring  the  de- 


TREATMENT.  453 

tachment  and  rejection  of  the  false  membrane.  In  this  respect, 
this  medication  may  be  compared,  to  a  certain  degree,  with 
treatment  by  emetics. 

If  it  is  desired  to  have  recourse  to  this  treatment,  we  intro- 
duce into  the  nostrils  of  the  child  some  snuff,  or,what  is  better, 
the  Saint-Ange  powder,  an  officinal  mixture  of  powdered  asa- 
rum,  betony,  and  vervain. 

Facts  which  may  be  cited  in  support  of  this  method  are  rare 
and  unsatisfactory. 

Antispasmodics, — Musk,  camphor,  opium,  assafoetida,  aether, 
belladonna  and  all  the  principles  of  the  antispasmodic  or  cal- 
mative remedies  have  been  used  in  the  treatment  of  croup  by 
the  ancient  authors :  Millar,  Thomson,  Underwood,  Cheyne, 
Vieusseux,  Weichmann,  Albers,  Ruysch,  Pinel,  Jurine,  Hen- 
drick,  and  others.  It  is  proper  to  state  that  these  remedies 
found  their  advantages  at  a  period  when  croup  was  confounded 
with  stidulous  laryngitis ;  since  the  differential  diagnosis  of 
these  two  diseases  is  definitely  established,  they  are  almost  ex- 
clusively reserved  for  the  latter  disease.  They  are  no  longer 
directed  against  croup  itself,  but  they  may  fulfill  some  in- 
dications when  there  is  a  predominance  of  the  nervous  ele- 
ment. 

Resume.  A  child  is  attacked  with  croup.  What  course 
should  the  physician  pursue? 

The  indications  are  general  and  local.  The  first  should  be 
met  above  all  else,  even  to  the  disparagement  of  the  second. 
Nourishment,  tonics  and  rest  combat,  as  far  as  it  is  possible, 
the  depressing  effects  of  the  poisoning  ;  even  in  case  of  failure 
one  may  have  the  consciousness  that  these  means  were  not  in- 
jurious. I  shall  not  say  as  much  of  the  treatment  which  has 
for  its  end  the  fulfilling  of  local  indications.  Often  ineffica- 
cious, they  may  be  dangerous,  for  example,  cauterization.  It  is 
necessary,  therefore,  to  consider,  first  of  all,  the  general  condi- 
tion. Perhaps  it  would  be  paradoxical  to  sustain  the  absolute 
uselessness  of  local  means.  However,  the  reader  could  con- 
vince himself  in  following  the  long  enumeration  of  modifiers  of 
the  false  membrane,  that  there  is  none  of  them  of  which  the 


454  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

action  is  certain.  If  he  must  not  neglect  them,  because  he 
should  endeavor  to  equalize  the  respiration,  he  should  be  care- 
ful to  avoid  sacrificing  the  general  indication.  This  would  be 
to  deprive  the  patient  of  his  best  chances  for  recovery.  We 
shall,  therefore,  reject  the  barbarous  methods  of  cauterization 
and  of  laryngeal  catheterism,  as  well  as  the  introduction  into  the 
bronchi,  of  irritant  vapors  of  which  the  most  certain  effect  is  to 
set  up  broncho-pneumonia,  that  complication  so  fearful  and  so 
frequent.  One  should  abandon  those  internal  remedies  of  which 
the  efficiency  is  always  doubtful,  however  little  they  may  be 
repugnant  to  the  patient  and  diminish  the  appetite  and  offend 
the  digestive  apparatus.  This  is  to  acknowledge  the  little  con- 
fidence inspired  in  us  by  the  specific  or  local  agents  which  we 
bring  to  bear  against  croup.  This  admission  is  painful,  but  it 
is  useful.  It  teaches  to  be  careful  in  the  use  of  these  remedies 
and  to  apply  them  only  on  condition  that  they  do  no  harm  : 
pfimnin  non  nocere. 

Observe  then  in  what  sense  the  treatment  may   be  planned : 

In  the  first  period,  the  local  applications  to  be  employed  are 
inhalations  of  lime-water,  lactic  acid,  bromine-water  and  solu- 
tions of  tannin  atomized.  If  the  age  of  the  patient  will  admit, 
the  mouth  should  be  held  open  during  the  inhalations  ;  if  it  is 
too  young,  we  content  ourselves  with  producing  around  the 
patient  a  medicated  atmosphere.  The  applications  should  be 
continued  long,  and  be  frequent;  ten  or  twelve  times  a  day  of 
a  half  hour  each. 

At  the  same  time  we  may  administer  internally  the  bromine 
solution,  the  formula  of  which  I  gave.  If  the  child  refuse  it  we 
shall  not  insist. 

In  the  second  period,  at  the  commencement,  we  administer 
fromo.50to  1.50  (7  to  20  grs.)  of  ipecac  mixed  inalittle  water. 
If  this  first  emetic  produces  the  desired  effect  without  fatigue, 
we  may,  if  the  disease  continues  its  course,  prescribe  a  second. 
It  is  rarely  advisable  to  go  beyond  that;  fatigue  occurs  as  well 
as  diarrhoea  ;  then  the  patients  no  longer  respond  to  the  action 
of  emetics.  If  the  occasion  presents  itself,  one  should  give,  in 
place  of  the  ipecac,  a  dose  of  from  0.005  ^o  O.O06  (Yisto  '/u  of  a 


TREATMENT.  455 

gr.)  of  apomorphia  introduced  by  the  hypodermic  method  on 
the  posterior  surface  of  the  forearm,  a  part  where  the  sensibil- 
ity is  not  so  acute.  This  remedy  would  be  especially  indicated 
if  the  other  emetics  have  failed. 

In  the  intervals  between  the  emetics  inhalation  should  be 
continued.  Under  the  influence  of  this  treatment  it  quite  often 
happens  that  the  disease  is  checked  and  the  false  membranes 
are  expelled:  but  still  oftener  it  passes  to  the  third  period  \  then 
it  is  that  the  indication  for  tracheotomy  is  established.  During 
the  use  of  local  remedies  the  general  treatment  will  not  be  neg- 
lected. Food  should  be  administered  in  all  forms,  following 
the  directions  that  I  gave  when  speaking  of  the  general  treat- 
ment of  diphtheria.  Tonics,  properly  so-called,  cinchona  es- 
pecially, at  the  rate  of  4.  (i5)  of  the  extract  daily,  will  not  be 
forgotten. 

Results.  By  the  use  of  this  treatment  we  reach  results 
worthy  of  being  signalized.  Whether  one  invokes  the  efficiency 
of  therapeutics, or  modestly  refers  the  recoveries  to  the  benign- 
ity of  the  malady,  a  certain  number  of  recoveries  have  been  ob- 
served. The  other  patients  were  operated  on  or  died  without 
operation,  relief  having  arrived  too  late,  or  tracheotomy  was 
contra-indicated  by  the  intensity  of  the  poisoning,  and  by  the 
generalization  of  diphtheria. 


456  DIPHTHERIA.    CROUP    AND    TRACHEOTOMY. 

THE    REGISTERS    OF    THE    SAINTE     EUGENIE     HOSPITAL,    KEPT 
FROM  ITS   FOUNDATION   IN   1854,   TABULATE  THE   CASES 
OF   CROUP   TREATED   IN   THAT   ESTABLISH- 
MENT. AS   FOLLOWS. 


Total    Cases. 

CASES  NOT  OPERATED  ON. 

Cases    of 

Years 

Recovered. 

Died. 

Left  not  Re- 
covered. 

Croup    Op- 
eration. 

1854 

17 

3 

5 

— 

9 

1855 

29 

5 

II 

— 

13 

1856 

41 

5 

12 

— 

24 

1857 

54 

9 

14 

I 

30 

1858 

146 

8 

12 

4 

122 

1859 

150 

20 

20 

I 

109 

i860 

65 

5 

20 

— 

40 

1861 

75 

4 

7 

— 

64 

1862 

109 

8 

3 

I 

97 

1863 

121 

13 

2 

106 

1864 

129 

8 

6 

— 

"5 

1865 

162 

13 

II 

I 

137 

1866 

140 

9 

15 

I 

"5 

1867 

108 

6 

6 

— 

96 

1868 

167 

14 

17 

I 

135 

1869 

141 

12 

25 

I 

103 

1870 

149 

5 

13 

— 

131 

1871 

"3 

9 

9 

2 

93 

1872 

201 

3 

10 

I 

187 

1873 

230 

2 

II 

4 

213 

1874 

184 

10 

10 

2 

162 

1875 

278 

33 

28 

6 

211 

2,809 

204 

265 

28 

2,312 

TREATMENT,  45/ 

In  2,809  cases  of  croup,  204,  that  is  i  in  13,  was  able,  there- 
fore, to  avoid  tracheotomy ;  265  died  without  operation  ;  and 
2,312  required  the  operation.  The  number  of  croup  cases  ar- 
rested in  their  course  is  comparatively  small ;  it  may  be  suf- 
ficient to  encourage  a  commencement  by  medical  means  with- 
out falling  into  the  great  mistake  [illusion)  of  the  value  of  this 
treatment.  One  should,  consequently,  be  very  cafeful  not  to 
depress  the  patients,  and  submit  them  to  surgical  treatment 
when  the  strength  is  exhausted.  Trousseau  stated  correctly 
that  subjects  who  have  reached  croupal  suffocation,  free  from 
previous  treatment,  have  the  most  numerous  chances  allotted 
them  for  recovery  after  tracheotomy.  Although  true  in  prin- 
ciple, this  precept  cannot  be  applied  without  limit.  The  duty 
is  incumbent  to  do  whatever  is  possible  to  bring  about  recov- 
ery without  tracheotomy.  Bnt  it  is  necessary  to  be  very  mod- 
erate in  the  use  of  emetics,  local  applications  and  so-called 
specifics.  These  means  are  often  useless,  and  always  depress- 
ing. Pushed  to  the  extreme  they  do  not  prevent  tracheotomy, 
but  influence  its  results  in  a  manner  most  deplorable. 


SURGICAL   TREATMENT. 


TRACHEOTOMY. 

When  nothing  has  been  able  to  arrest  the  course  of  the  dis- 
ease, and  asphyxia,  already  commenced,  threatens  to  become 
complete,  there  remains  but  one  hope — recourse  to  tracheot- 
omy. This  valuable  operation  has  rescued  from  death  a  large 
number  of  patients  otherwise  irrevocably  lost.  Its  populariza- 
tion will  be  Trousseau's  highest  claim  to  recognition  by  pos- 
terity. 

Coelius  Aurelianus  and  Galen  accredit  Asclepiades  with  hav- 
ing extolled  tracheotomy  in  angina  suffocans  at  the  time  of 
Cicero.  These  authors  transmit  nothing  of  the  operative  pro- 
cedure which  Asclepiades  may  have  employed,  nor  has  Are- 
taeus  who  unites  with  Coelius  Aurelianus  in  severely  criticising 
this  operation. 

The  first  surgeon  of  antiquity  of  whose  manner  of  operating  we 
have  any  knowledge  is  Antyllus,  cited  by  Paulus  /Egineta. 
This  surgeon  points  out  very  definitely  that  the  operation  has 
for  its  object  the  relief  of  suffocation  caused  by  an  inflammation 
seated  in  the  pharynx  (throat)  above  the  larynx.  He  insists 
upon  its  advantage  before  the  trachea  is  invaded.  He  makes 
the  incision  transversely  below  the  third  or  the  fourth  ring  of 
the  trachea,  being  careful  not  to  cut  the  cartilages,  but  the 
membrane  which  unites  them. 

The  recommendations  which  he  gave  concerning  the  details 
of  the  operation,  the  position  of  the  patient,  and  the  anatomy 
of  the  part  have  not  fallen  into  oblivion,  for  the  method  was 
brought  forward  again  a  few  years  since  by  Miquel,  of  Am- 
boise.  Rhazes,  Mesne,  and  Avicenna  spoke  of  bronchotomy  as 

(458) 


SURGICAL    TREATMENT.  459 

a  supreme  resource  in  suffocative  quinsy ;  but  they  omitted  the 
details  of  the  operation. 

At  the  time  of  Albucasis,  according  to  his  statement,  no  one 
practiced  tracheotomy.  Avenzoar  had  the  idea  of  trying  the 
operation  on  a  goat.  The  animal  having  recovered,  he  con- 
cluded that  wounds  of  the  trachea  were  not  very  fatal.  In  the 
Middle  Ages  tracheotomy  had  become  a  legend.  It  is  neces- 
sary to  advance  to  the  middle  of  the  sixteenth  century  to  find 
an  authentic  example  of  it.  We  find  one  in  1546  by  Ant. 
Musa  Brassavolo,  physician  to  the  Duke  of  Ferrare,  who  suc- 
cessfully performed  the  operation  on  a  patient  who  was  at- 
tacked with  a  hopeless  suffocative  angina.  About  half  a  cen- 
tury later  Santorio,  as  stated  by  Malavicini,  first  used,  in  per- 
forming the  operation,  a  trochar  of  which  he  left  the  canula 
three  days  in  the  wound.  This  procedure — laryng.'Centesis — 
was  again  recommended  in  1748  by  Garengeot.  This  surgeon, 
however,  recommended  incising  the  integument  previously, 
without  disturbing  the  muscles,  at  least  in  thin  persons. 

A  little  later,  Heister  recommended  a  mode  of  operating 
which  approximated  the  one  now  employed.  Decker,  Bou- 
chot,  Barbeau-Dubourg  and  Richter,  invented  special  instru- 
ments for  facilitating  the  puncture  which  wer«  called  broncho- 
tomes.  But  Van  Swieten  had  criticised  already  this  method 
of  doing  what  he  considered  as  very  dangerous.  Fabricius  ab 
Acquapendente  advised  the  use  of  a  canula  with  wings  {ailce), 
a  simple  canula  being  exposed  to  fall  into  the  trachea. 

Casserio  argued  in  favor  of  tracheotomy,  from  all  the  cases 
of  wound  of  the  trachea  which  had  recovered  up  to  that  time. 
He  gave  a  very  complete  description  of  the  operation.  Habi- 
cot  recommended  it  in  dangerous  inflammations  of  the  trachea. 
He  had  occasion  to  practice  it  in  a  case  of  a  foreign  body  in 
the  oesophagus  which  strongly  compressed  the  trachea.  Marcus 
Aurelius  Severinus  pronounced  a  grand  eulogy  on  this  opera- 
tion;  as  well  as  did  Rene  Moreau,  and  the  Portuguese,Thomas 
Rodriguez  de  Veiga.  Bernard  and  Gherli  both  practiced  it 
with  success.  Louis,  in  a  celebrated  memoir,  contributed 
greatly  to  attract  attention  to  the  subject. 


460  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

Vicq  d'Azyr,  in  1776,  published  a  work  on  crico-thyroidean 
laryngotomy.  Crawford  and  Michaelis  endeavored  to  estab- 
lish the  indications  for  it.  In  this  long  period  tracheotomy 
was  probably  performed  in  some  cases  of  croup,  but  certainly 
also  in  many  other  affections.  We  do  not  possess  data  upon 
this  point  only  from  the  time  of  Home  (1765),  the  historian  of 
croup.  Without  practicing  the  operation  he  recommended  in- 
cision of  the  trachea  as  a  dei-nier  ressort,  in  the  period  of  suffo- 
cation, either  for  preventing  asphyxia  or  to  favor  the  expulsion 
of  false  membranes.  A  little  later,  in  17S2,  tracheotomy  was 
successfully  performed  by  John  Andree,  a  surgeon  of  London. 
The  report  of  this  is  given  by  Borsieri  in  his  Institutes.  Stoll 
(1786),  also  recommended  the  operation,  but  it  does  not  ap- 
pear that  he  ever  saw  it  practiced. 

At  the  commencement  of  the  present  century  Chaussier 
recognized  it  as  the  only  means  capable  of  preventing  suffoca- 
tion; and  recommended  not  to  wait  till  the  lungs  were  en- 
gorged. Meanwhile  it  had  furnished  but  few  results,  and  it 
was  very  seldom  practiced  ;  the  discouragement  was  general. 
Also,  at  the  time  of  the  great  competition  of  1808  all  the  com- 
petitors and  the  secretary  rejected  tracheotomy.  We  must, 
however,  except  Caron,  who  sustained  with  great  energy  and 
indefatigable  perseverance,  the  cause  of  the  operation.  But 
his  arguments,  however  correct  they  may  have  been,  required 
the  support  of  successes  ;  but,  instead  of  that,  one  tracheotomy, 
performed  by  him  in  the  meantime  tended  only  the  more  to 
the  reverse.  Nevertheless,  he  did  not  consider  himself  beaten. 
Encouraged  by  the  fortunate  result  of  a  tracheotomy  made  for 
a  foreign  body  in  the  air-passages,  he  offered  a  prize  of  a 
thousand  francs  to  anyone  who  would  cure  a  case  of  croup  by 
the  aid  of  this  operation. 

England,  in  18 14,  furnished  another  case  of  cure  of  croup  by 
tracheotomy  performed  by  Thomas  Chevalier,  of  London. 

In  France,  Bretonneau  changed  the  status  of  things.  Not 
satisfied  with  giving  a  full  history  of  the  disease,  the  celebrated 
physician  of  Tours  was  able,  by  his  persevering  firmness  ("  sa 
perseverant  obstination  ")  to  reanimate  the  confidence  of   phy- 


SURGICAL    TREATMENT.  4^1 

sicians,  and    to    enable    them    to    obtain    unexpected    results. 

After  two  unfortunate  attempts,  in  1818  and  in  18 19,  he  had 
the  happiness  to  save,  in  1825,  the  daughter  of  his  dear  friend, 
the  Count  of  Puysegur.  If  Bretonneau  succeeded  where  so 
many  others  had  failed,  it  was  because  he  understood  that  it 
was  not  sufficient  to  make  an  opening,  more  or  less  narrow,  for 
the  air,  and  to  maintain  it  with  a  canula  formed  from  the  end 
of  a  gum-elastic  catheter,or  to  reclose  it  immediately  after  hav- 
ing extracted  the  false  membranes  which  were  immediately  re- 
produced, but  that  it  was  necessary  to  incise  somewhat  exten- 
sively, and  to  keep  the  trachea  open  by  means  of  a  large  can- 
ula during  all  the  time  necessary  for  the  elimination  of  these 
concretions.  His  experiments  on  animals  had  shown  him  that 
the  trachea  could  tolerate  the  contact  of  a  foreign  body  for  a 
sufficiently  long  time.  This  fact  had  an  immense  influence. 
Several  tracheotomies  were  performed,  but  failing  to  observe 
the  precepts  of  Bretonneau,  particularly  the  use  of  the  double 
canula,  we  see  a  new  series  of  failures  returning.  In  the  mean- 
time. Prof.  Stolz  performed  one  successful  operation  at  Stras- 
burg,  in  1829. 

It  was  given  to  Trousseau  to  popularize  tracheotomy.  It  is 
to  this  illustrious  teacher,  to  his  brilliancy,  to  the  authority 
of  his  word,  to  the  perfection  which  he  added  to  the  after- 
treatment,  to  the  numerous  successes  of  his  practice  that 
tracheotomy  owes  its  extension,  first  in  France  and  then 
abroad.     His  first  success  dates  from  1830;  he    published  it  in 

1833. 

After  this  epoch  numerous  operations  were  made  ;  Breton- 
neau and  Trousseau  continue  to  furnish  examples. 

In  1839  a  discussion  arose  in  the  Academy  of  Medicine  in 
regard  to  a  case  of  tracheotomy  which  terminated  fatally,  re- 
ported by  M.  Gendron.  Bricheteau,  the  secretary  of  the  commis- 
sion, proved  that  there  could  be  counted  eighteen  recoveries 
in  sixty  operations.  The  debates  which  followed  gave  as  re- 
sults the  following  figures  : 


462  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 


Operators. 

Messers.  Amussat 

Number  of 
Tracheotomies. 

5 

Successes. 
0 

Baudelocque  (operat.  done  at  Hop 
des  Enfants  Malades)    - 

lital 

15 

0 

Blandin 

- 

5 

0 

Bretonneau 

_             _             _ 

17 

5 

Gerdy 
Roux 

-             -             - 

6 

4 

4 
0 

Trousseau    - 

_ 

80 

20 

Velpeau 

_             _             _ 

6 

0 

Total        -         -  -  -  1 38  29 

This  was,  even  then,  an  interesting  result  since  it  gave 
about  one  success  in  five  operations,  or,  correctly,  i  in  4.75. 
Meanwhile,  the  operative  procedure,  and  especially  the  after- 
treatment,  was  badly  understood  by  many  of  the  operators. 
We  may,  in  this  way,  explain  the  terrible  results  of  surgeons 
such  as  Velpeau,  Blandin  and  Roux.  In  1844  we  can  count 
212  operations  with  40  recoveries. 

When  Trousseau,  in  1848,  took  charge  at  Hopital  des  En- 
fants, the  results  of  tracheotomy  in  that  establishments  were 
deplorable.  Forty-nine  operations  had  failed  with  the  excep- 
tion of  a  single  one,  of  which  the  report  was  not  yet  published 
at  the  time  of  his  celebrate{^  report  on  catheterism  of  the  lar- 
ynx (tubage  de  la  glotte);  it  was  communicated  to  the  Societe 
Medicale  des  Hopitaux,  at  a  later  period  by  Roger.  Thus 
disfavor  was  complete.  One  success  obtained  by  Trousseau  in 
his  department  aided  him  in  overcoming  the  aversion  of  the 
other  physicians  of  the  establishment.  The  ice  was  broken  ; 
a  new  era  dawned.  The  operation  was  practiced  on  a  large 
scale  by  Guersant  and  by  the  assistants  at  the  hospital. 
Thanks  to  the  improvements  introduced  by  Trousseau  in  the 
after-treatment,  and  to  the  use  also  of  the  double  canula,  the 
results  soon  became  very  satisfactory.  From  1849  to  1858 
there  were  466  tracheotomies  performed,  giving  126  successes, 
that  is,  more  than  one-fourth. 


SURGICAL  TREATMENT.  463 

At  the  same  period  the  hospital  Sainte-Eugenie,  established 
four  years  previously,  reported  198  tracheotomies,  of  which  39 
recovered,  that  is,  l  in  5.  It  was  at  this  time  that  the  work 
of  Bouchut  on  catheterism  of  the  larynx  appeared,  a  work  in 
which  the  author,  finding  an  increase  in  the  mortality  of  croup 
at  Paris  for  some  years  past,  attributed  this  increase  to  trache- 
otomy without  considering  that  the  rise  in  the  mortality  coin- 
cided with  the  increase  in  the  number  of  croup  cases.  Trous- 
seau, finding  himself  attacked  on  his  favorite  subject,  assumed 
the  defense  of  tracheotomy.  His  admirable  report  to  the  Acad- 
emy of  Medicine  was  followed  by  a  discussion  which  still  re- 
mains celebrated.  His  powerful  discourse,  to  which  was  added 
the  argument  so  authoritative  of  Bouvier,  had  the  effect  of 
again  placing  the  question  in  its  true  light.  Vainly  did  Mal- 
gaigne,  who  had  employed  against  tracheotomy  all  the  re- 
sources of  his  able  reasoning  and  his  biting  sarcasm,  attempt 
to  weaken  the  value  of  the  figures  presented  by  Trousseau  by 
presenting  such  unfavorable  statistics  as  the  following : 


Number  of 

Operators. 

Tracheotomies. 

Recoveries. 

Gosselin 

- 

- 

23 

0 

Michon 

- 

- 

20 

2 

Laugier 

- 

- 

8 

I 

Nelaton 

- 

- 

36 

3 

Monod 

- 

(a 

bout)  40 

0 

Thierry    < 

on 
on 

children 
adults     - 

_ 

37 
3 

3 
0 

Malgaigne 

- 

- 

8  or  10 

I  . 

It  was  shown  from  the  discussion  that,  though  the  efforts  of 
these  skilful  surgeons  had  not  been  followed  by  better  results, 
it  should  not  be  charged  to  the  operation  itself,  nor  to  the 
manner  in  which  it  had  been  executed,  but  that  these  eminent 
surgeons,  having  completed  the  operation,  considered  their 
duty  performed,  and  retired,  leaving  the  patients  in  the  hands 
of  ordinary  physicians  who  at  that  time  were  little  acquainted 
with  the  necessary  treatment  of  these  patients.     It  was  proved 


464  DIPHTHERIA,  CROUP  AND  TRACHEOTOMY. 

that  if  the  tracheotomies  performed  in  the  hospitals  most  fre- 
quently by  the  assistants,  gave  such  remarkable  results,  it  did 
not  depend  alone  upon  the  fact  as  had  been  insinuated,  that 
the  patients  were  operated  on  without  necessity,  but  upon  the 
fact  that  the  after-treatment  was  performed  properly  in  these 
institutions  by  attendants  thoroughly  trained. 

This  was  the  explanation,  at  first,  of  these  surprising  differ- 
ences. The  fact  was  so  fully  recognized  that  it  became  an 
established  principle,  still  true  to-day,  that  families,  situated 
in  straitened  circumstances,  give  their  children  many  more 
chances  for  recovery  by  having  them  operated  on  at  the  hos- 
pital. 

As  proof  of  the  difference  in  the  results  obtained  by  the  op- 
eration followed  by  rational  treatment,  Trousseau  cited  the 
following  statistics : 

I.  Those  of  Bardinet,  of  Limoges,  comprising  the  tracheot- 
omies done  by  himself  and  by  several  physicians  of  the  same 
city  : 


Operators. 
Boullaud 
Thouvenet 
Deperet 
Roche    - 
Lemaiffre 
Saymondaud 

Y   *    *    * 

"Mazard  -  - 
Bleynie  -  - 
Bardinet 

Total  _  -  -  58  17 

of  which  the  general  result  is  i  recovery  in   3.41. 

2.  The  reports  of  the  operations  performed  by  several  phy- 
sicians from  different  parts  of  France  : 


Number  of 

Tracheotomies. 

Recoveries. 

20 

6 

13 

3 

7 

I 

I 

0 

3 

0 

I 

0 

I 

0 

3 

I 

3 

2 

6 

4 

SURGICAL  TREATMENT.  465 


Number  of 

Operators. 

Tracheotomies. 

Recoveries 

Saussier,  of  Troyes, 

6 

3 

Beylard,  of  Paris, 

13 

4 

Moynier,  of  Paris, 

17 

8 

Archambault,  of  Paris,    - 

21 

8 

Perrochaud,  of  Boulogne, 

3 

2 

Delarue,  of  Paris, 

3 

I 

Laloi,  of  Belleville, 

6 

3 

Viard,  of  Montbard, 

2 

I 

Petel,  of  Cateau, 

9 

4 

Baudin,  of  Nantua, 

4 

3 

Dubarry,  of  Condom,     - 

5 

2 

Total       -        -  -  -  89  39 

which  gives  i  recovery  in  2.28  operations. 

3.  Those  of  several  distinguished  surgeons  of  Paris,  who  had 
studied  at  the  school  of  Trousseau,  and  comprehended  the  im- 
portance of  the  after  treatment : 

Operators. 
Richet, 
Follin, 
Broca, 
Richard, 
Demarquay,    - 

Total,  -  -  -         39  17 

that  is,  I  recovery  in  2.29  operations : 

The  summing  up  of  these  three  tables  in  186  operations,  gives 
73  recoveries  or  i  recovery  in  2.54  operations. 

On  the  other  hand  the  remarkable  works  of  Barthez,  Roger, 
and  Germain  See  had  demonstrated  in  an  irrefutable  manner 
a  decided  increase  of  croup  since  1840.  Therefore,  the  aug- 
mentation in  the  number  of  deaths  corresponds  to  the  consid- 
erable rise  in  the  number  of  croup  cases ;  consequently  tra- 
cheotomy, far  from  increasing  the  mortality,  rescues  from  death 
a  large  number  of  patients. 


Number  of 

Tracheotomies. 

Recoveries 

9 

5 

7 

2 

12 

6 

5 

2 

6 

2 

466  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

Erom  this  period,  tracheotomy  has  extended  not  only  in 
France,  but  to  other  countries.  It  is  at  present  practiced  in 
ever>'  country  of  Europe  where  it  has  acquired  the  same  claim 
to  public  recognition. 

It  is  interesting  to  state  what  we  know  of  its  results  in  the 
hospitals. 

French  Statistics. 

Aside  from  the  statistics  of  the  hospitals,  we  have  compara- 
tively few  documents,  but  the  former  are  of  great    importance. 

The  following  are  such  as  I  have  collected  from  the  regis- 
ters of  the  two  hospitals  for  children  in  Paris : 


SURGICAL     TREATMENT. 
HOPITAL  SAINTE-EUGENIE. 


467 


CROUP  CASES  TRACHEOTOMIZED. 

Proportion  of 

Years. 

Dismissed 
Cured. 

Died. 

Dismissed 
not  Cured. 

Total. 

reco  vertes 
to  the  whole 
number. 

1854 

2 

7 

— 

9 

I  to  4.S0 

1855 

4 

9 

— 

13 

I  to  3.25 

1856 

5 

19 

— 

24 

I  to  4.80 

1857 

5 

24 

I 

30 

I  to  6.00 

1858 

23 

95 

4 

122 

I  to  S.29 

1859 

17 

88 

4 

109 

I  to  6.41 

i860 

7 

31 

2 

40 

I  to  S.7  I 

1861 

16 

45 

3 

64 

I  to  4.00 

1862 

23 

67 

7 

97 

I  to  4.2  r 

1S63 

35 

68 

3 

106 

I  to  3.02 

1864 

26 

85 

4 

IIS 

I  to  4.42 

1865 

44 

87 

6 

137 

I  to  3. 1  I 

1866 

36 

76 

3 

IIS 

I  to  3,19 

1867 

29 

63 

4 

96 

I  to  I.T,  I 

1868 

31 

lOI 

3 

135 

I  to  4.35 

1869 

31 

70 

2 

103 

I  to  3.35 

1870 

42 

85 

4 

131 

I  to  3. 1  I 

1871 

12 

78 

3 

93 

I  to  7.75 

1872 

39 

138 

10 

187 

I  to  4.79 

1873 

32 

170 

II 

213 

I  to  6.65 

1874 

23 

132 

7 

162 

I  to  7.04 

1875 

27 

175 

9 

211 

I  to  6.48 

509 

1,713 

90 

2,312 

I  in  4.54 

468 


DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 
HOSPITAL  DES   ENFANTS   MALADES.i 


CROUP  CASES  TRACHEOTOMIZED. 

Proportion  of 

Years. 

Dismissed 
Cicred. 

Died. 

Dismissed 
not  Cured. 

Total. 

reco  ver  ies 
to  the  whole 
number. 

1851 

14 

17 

— 

31 

I  to  2.21 

1S52 

18 

43 

— 

61 

I  to  3.38 

1853 

9 

52 

— 

61 

I  to  6.77 

1854 

14 

29 

— 

43 

I  to  3.07 

1855 

12 

34 

— 

46 

I  to  3.83 

1856 

16 

33 

3 

52 

I  to  3.25 

1857 

16 

54 

— 

70 

I  to  4.37 

1858 

34 

73 

2 

109 

I  to  3.20 

1859 

41 

"5 

4 

160 

I  to  3.90 

i860 

24 

lOI 

3 

128 

I  to  5.30 

1861 

29 

72 

I 

102 

I  to  3.49 

1862 

27 

112 

6 

145 

I  to  5.37 

1863 

46 

86 

10 

142 

I  to  3.08 

1864 

40 

105 

8 

153 

I  to  3.82 

1865 

40 

86 

4 

•    130 

I  to  3.25 

1866 

27 

71 

3 

lOI 

I  to  3.74 

1867 

15 

57 

4 

76 

I  to  5.06 

1868 

26 

36 

— 

62 

I  to  2.38 

1869 

12 

54 

— 

66 

I  to  5.50 

1870 

21 

43 

— 

64 

I  to  3.04 

1871 

16 

27 

— 

43 

I  to  2.67 

1872 

30 

71 

9 

no 

I  to  3.66 

1873 

26 

79 

2 

107 

I  to  4. 1 1 

1874 

23 

81 

4 

108 

I  to  4.69 

1875 

38 

130 

13 

181 

I  to  4.76 

614 

1,661 

76 

2,351 

I  in  3.82 

'The  tracheotomies  were  not  borne  on  the  register  previous  to  185 1. 


SURGICAL    TREATMENT. 


409 


In  1864  Guersant  reported  that  he  had  operated,  in  all,  156 
times,  from  which  he  had  28  recoveries ;  and  he  observed  that 
up  to  1845,  the  period  at  which  he  began  to  use  the  double 
canula  and  the  cravat,  he  had  only  two  recoveries  in  32  opera- 
tions. His  statistics  may,  therefore,  be  divided  into  two 
groups : 

Operations.         Recoveries. 

1st.     Between  1834  and  1845,         -       32  2 

2d.      After  1845,  -  -  124  26 


Total. 


156 


28 


In  1865,  in  the  second  edition  of  his  Clinical  Medicine, TxomlS- 

seau    said   he    had   performed  two   hundred  tracheotomies,  ot 

which  more  than   one-fourth   recovered.     Statistics   from  the 

practice  of  other  French  physicians  are  to  be  found  in  medical 

literature.     They  are  as  follows  : 

Number  of 


Operators. 

Tracheotomies. 

Recoveries. 

Isnard,    - 

- 

- 

4 

2 

Baizeau,  Paris,    - 

- 

- 

12 

4 

Lenantais,  Nantes, 

- 

- 

31 

5 

Calvet,  Castres,  - 

- 

- 

16 

8 

Boeckel,  Strasburg, 

- 

- 

33 

12 

Ehrmann,   Mulhouse 

- 

- 

14 

7 

Klippel, 

- 

- 

3 

0 

Battenburg, 

- 

- 

3 

I 

Werner,  - 

- 

- 

5 

2 

Koechlin, 

- 

- 

6 

2 

Schoelhammer,  (Haut 

Rhin) 

- 

7 

6 

Belin,  Colmar,    - 

- 

- 

4 

I 

MuUer,    - 

- 

- 

I 

0 

Marquez, 

- 

- 

I 

I 

Macker,  - 

- 

- 

I 

I 

Radat,    - 

- 

- 

I 

I 

Duclout, 

- 

- 

2 

0 

Godefroy,  of  Vienna, 

- 

- 

12 

2 

Michalski,  Charny, 

- 

- 

3 

2 

Marc  See,  Paris  (adult] 

1- 

- 

I 

0 

Total,      - 

- 

> 

160 

57 

470  diphtheria,  croup   and   tracheotomy. 

Other    Countries. 

Portugal. — The  introduction  of  tracheotomy  into  Portugal 
dates  from  1835,  and  it  is  due  to  Martiniano  Nunez  da  Regate; 
this  was  a  case  of  failure  which  passed  almost  unnoticed. 

In  185 1  da  Silva  adopted  the  operation,  and  had  four  rscov- 
eries  in  fourteen  tracheotomies.  The  first  three  resulted  in 
death. 

Prof.  Antonio  Mar,  Barbosa  had  6  recoveries  in  15  opera- 
tions. From  this  date  the  Portuguese  physicians  have  contin- 
ued to  advance  with  equal  courage  and  success.  According 
to  information  kindly  furnished  me  by  Prof.  Barbosa  the  pres- 
ent status  of  tracheotomy  in  Portugal  is  as  follows : 

Since  1 863  Prof.  Barbosa  has  performed  8  additional  opera- 
tions, of  which  3  recovered,  which  make  a  total  of  23  cases 
and  9  recoveries. 

And  Prof.  Theotonio  da  Silva  has  now  21  cases,  with  8  re- 
coveries. To  these  should  be  added  15  more  caees  with  4  re- 
coveries, in  the  practice  of  Messrs.  Henriques  Teixeira.  Jose 
Gualdino  de  Carvalho,  Teixeira  Marques,  and   Alves    Branco. 

In  tabular  form  they  are  as  follows : 


Number  of 

Operators. 

Tracheolomies. 

Recoveries. 

Proportions. 

Antonio-Maria  Barbosa, 

-        -         23 

9 

I  in  1.5s 

Theotonio  da  Silva, 

21 

8 

I  in  2.62 

Other  operators, 

■        -         15 
-       59 

4 
21 

I  in  3.74 

Total,        -        -        -        - 

I  in  2.80 

These  results,  so  remarkable,  do  great  honor  to  our  Portu- 
guese brethren,  and  worthily  reward  these  able  advocates 
of  this  operation  in  the  Iberian  peninsula. 

Spain. — The  researches  made  by  Prof.  Barbosa  in  this 
country,  at  the  time  of  his  memoir  on  tracheotomy,  show  that 
this  operation  is  rarely  practiced  in  Spain.  It  has  been  tried 
five  or  six  times  only  and  then  without  success.  The  last  was 
by  Prof.  Vicente  Asnero,  in    1859. 

Spanish  physicians,  little  encouraged  by  these  results,  have, 
according  to  Barbosa's  statement,  but  little  confidence  in  the 
treatment  of  croup  by  tracheotomy. 


SURGICAL  TREATMENT.  4/1 

Belgium. — In  i860,  Dr.  Henriet,  of  Brussels  counted  eight 
operations  with  four  recoveries. 

According  to  a  manuscript  communication  transmitted  by 
the  kindness  of  Warlomont,  the  statistics  of  tracheotomies  per- 
formed from  1870  to  1875  in  the  practice  of  that  distinguished 
physician  at  Saint  Peter's  Hospital  in  Brussels   are  as  follows  : 

Years.  No.  of  Tracheotomies.         Recoveries. 

1870  -  -  -  3  I 

1871  .  .  -  3  O 

1872  -           -           -  4  *  o 

1873  -           -           .  7  I 

1874  ...  9  4 

1875  ...  9  ^ 

Total       .  -  .  35  8 

In  adding  these  to  the  above  we  have  twelve  recoveries  in 
forty-three  operations,  or  i  in   3.50. 

Dr.  Henriet  remarked  that  the  cases  operated  on  comprised 
in  this  report,  in  many  instances,  had  been  treated  by  the 
most  irrational  means,  and  nearly  all  were  admitted  to  the 
hospital  in  an  advanced  stage  of  asphyxia.  In  private  prac- 
tice the  number  of  recoveries  is  perceptibly  higher. 

Italy. — If  we  can  judge  from  public  documents,  tracheotomy 
is  seldom  practised  in  Italy.  It  has  been  performed  by  Dr. 
Valerani,  of  Turin,  who  had  one  recovery  in  three  cases. 

In  Tuscany,  where  a  severe  epidemic  of  diphtheria  has  pre- 
vailed for  ihe  last  ten  years,  tracheotomy  is  much  dreaded, 
rarely  practised  and  always  at  the  last  extremiiy.  Prof.  Rosati, 
of  Florence  has  operated,  or  seen  the  operation  in  nine  cases, 
only  a  single  one  of  which  recovered.  He  attributed  this  ter- 
rible mortality  to  excessive  temporization — postponement. 

Germany. 

Slow  to  be  adopted  in  Germany,  tracheotomy  is  now  in 
common  practice  in  this  country.  The  results  there  are  very 
favorable. 


472 


DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 


Germany. 

Operators  and  Country.  No.  of  Tracheotomies.  Recoveries. 

[Passavant,  Frankfort,  from  1851  to  1882         -  229  67] 

Baum,  Goettingen,         -----  31  12 

Fock  and  others,  Madgeburg,         -        -        -  43  18 

Roser,  Marbourg,            -__-.42  19 

Uhde  and  others,  Braunschweig,  -        -        -  81  21 

Simon,  Rostock, 22  j  f"^  ^."  ^"  f  "^^  I     6 

'  |_termma  d  fat  ly  J 

Burow,  Koenigsburg,     -----  59  7 

Schmidt,  Leipzig  City  Hospital,  from  1878  to  15  2 

1883            -__.-..  310  67 

Peltzer,  Bremen,  from  Oct  1883  to  Mar.  1884        88  12 

Bartels,  Kiel,         ------  61  17 

Max  Bartels,  Berlin.    Statistics   of  the  opera- 
tions   performed  in  the   service    of    Prof. 
Wilms  at   the   Bathanien    Hospital,    from 
1861  to  1872  and  comprise  the  100  publish- 
ed by  Giiterbock  in  1867     -         -         -         -  335  I03 

Eberth,  Berlin,  1857  to  1865           -        -        -  13  6 

Busch,  Berlin,        ---__-  72  10 

Von  Kopl      -------17  II 

Morath            -                ---.-i  I 

Stelzner,  Dresden,           -                -        -         -  12  4 

Miiller,  Cologne,  1862  to  1869        -        -        -  45  15 

Molendzniski,  Lemberg,         .         -        .        ■  2     one  an  adult.  o 

Oelschlaeger,  Dantzig.  1856  to  1869      -        -  12  I 

Reiffer,  Frauenfeld,        -----  18  8 

Hueter,  Rostock,            -----  29  7 

Birnbaum,  Darmstadt,  1873  to '83           "        "  HO  47 


[At  Leipzig  (City  Hospital)  from  1878  to  1883  inclusive,  there  were  310  operations 
of  tracheotomy  for  diphtheria,  of  which  243  died. 

From  October,  1883,  to  March,  1884,  inclusive,  there  were  88  cases  of  tracheotomy 
during  an  epidemic,  of  which  76  (86.4%)  died. 

The  non-operated  cases  of  diphtheria  received  at  the  same  institution  during  the 
same  period  were  mostly  treated  with  turpentine — "a  teaspoonful  of  a  mixture  con- 
t  lining  a  little  spirit  of  ether  being  given  three  times  a  day." — Van  Arsdale.  Ann, 
of  Surg.    Vol.  L    No.  2.     1885. 

Monti  (1884)  collected  12,736  cases  with  3,409  recoveries. — Ann.  of  Surg.  Vol, 
I.  p.  581.] 


surgical    treatment.  4/3 

Bavaria. 

Operators.  No.  of  Tracheotomies.  Recoveries. 

Manner,  Munich,        -----17  2 

[Fifty-eighth  Congress  of  German  Nat.  and 
Physicians,  Strassburg,  Sept.  18  to  23,  1885 
(Med.  Record.  Nov.  14,  1885).  Ranke,  of 
Munich,  tracheotomy,  7V2  years,         -        -        45  19] 

Austria. 

[Monti,  1884,  collected,  -        _        _        .   12,736  3»409] 

Wiederhofer,  Vienna,  1864.     Statistics  of  St 
Annen-Kinderspital    [The  latest   statistics 

is  that  over  50%  recovered  (1884)]      -        -         19  2 

Prague,  statistics  of  Kinderspital,            -         -        24  6 

Steiner,  four  years  in  Prague,          -         -        -         52  18 

[Ziemssen  cyclopaedia,  Children's  Hosp.,  Prague,  lOO  32] 

Balassa,  Pesth,       ------2  2 

[The  latest  statistics  of  tracheotomy  at  St  Annen  Kinderspital  is  that  over  50% 
of  the  cases  recovered. — Brit.  Med.  Jour.     July  19,  1884.] 

Russia. 

Operators.  No.  of  Tracheotomies.  Recoveries. 

Symwrhid,  St.  Petersburg,    -        -        -        -  4  2 

Froebelius,  "  -        -        -        _  2  O 

Holland. 

Titanus,  Amsterdam      -----        80  28 

Switzerland. 

Billroth,  Zurich,     ------12  I 

Revilliod,  Geneva,         -----        87  38 

D'Espine,  Geneva,        -----         15  6 

Picot,  Geneva,        ------4  2 

Rapin,  Geneva,      ------30  g 

The  results,  so  brilliant  in  the  Geneva  practice,  have  been 
communicated  to  me,  as  well  as  a  number  of  other  valuable 
documents  by  my  friend  Dr.  d'Espine,  one  of  the  most  distin- 
guished pupils  of  Barthez. 

England. 

Tracheotomy  is  but  little  practised  in  England,  where  it  has 
few  recoveries  as  we  learn  from  Dr.  West. 


474  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

The  followinfr  figures  which  I  take  from  the  memoir  of  Dr. 
J.  Solis-Cohen,  of  Philadelphia,  while  fully  proving  the  first 
proposition  above,  do  not  equally  establish  the  correctness  of 
the  second. 

Operators.                                     No.  of  Tracheotomies.  Recoveries. 

Spence,  Edinburg,          .-,---         87  28 

Buchanan,  Glasgow,      -----        39  "                         ^3 

Cruickshank,          ------n  8 

H.  W.  Fuller,  statistics  of,      -        -        -        -          7  3 

Conway  Evans,      ------5  I 

Henry  Smith,  London,           -        -        -        -          3  o 

Ransom,  Nottingham,  -----          3  o 

West,  London,       ------30  7 

Total, 1S5  60 

[In  the  report  of  the  commissioners  made  to  the  Royal  Med.  Chirurg.  Society 
(1879)  on  the  relations  of  membranous  croup  and  diphtheria,  Dickinson,  chairman, 
reports  tracheotomy : 

Cases,  18.  Recoveries,    6. 

Dr.  Fagge,  class  I,            -----        24  2 

Dr.  Fagge,  class  II  and  III,     -        -        -        -         19  5 

Dr.  Gee's,  from  1853  to  187S,  -        -        -        -        34  3 

Total,  -        - 95  16 

More  recently  R.  W.  Parker  reports     -        -        -         32  17] 

The  proportion  of  recoveries  would  be  i  in  3.08.  The  hos- 
pitals of  London  furnish  results  unimportant  numerically,  and 
but  little  encouraging. 

Hospitals.  No.  of  Tracheotomies.  Recoveries. 

c  /-  >    Tj       -.  1  <;     f  I  of  the  fatal  cases'!     » 

St.  George's  Hospital,        -        -        -        -        6   <  ,^  r ^     >   3 

o  r       >  ^  -yyas  1 0  yrs  01  age.    J     "^ 

Dreadnought  Hospitals  hip,  -  -  -  i  o 

Metropolitan  Free  Hos  ital,  -  -  -  i  O 

Hospital  for  Sick  ChiKlien,  "  "  -  3  o 

King's  College  Hospital,     -  -  -  -  i  o 

Middlesex  Hospital,            -  _  .  -  6  (one  oper.  on  an  adult)   o 

St.  Mary's  Hospital,             -  _  .  -  i  o 

Addenbrooke's  Hospital,  Cambriilge,  -  i  I 

Total,      -------20  4 

America. 
The  physicians  of  the  United  States    practice    tracheotomy 
largely.     Some   portions   of  the  country  are  less  favored  than 
others. 


SURGICAL     TREATMENT.  4/5 

[The  following  two  quotations  are  taken  from  the  report  of  Dr.  Wm.  M.  Mastin, 
of  Mobile,  Ala.,  on  tracheotomy  for  croup  in  the  United  States: 

"Total  number  of  operations  tabulated  amount  to  863  (of  these  296  were  o'?///- 
t/teridc cronji,  vfhh  41  cures  and  2^^  deaths.  \()<\psendo-iitemhranous  troup,^\'On. 
47  cures  and  147  deaths.  373  croup  in  s^eneral  (their  i?.v(7(/ nature  not  being  known), 
with  90  cures  and  283  deaths;  with  178  recoveries  and  685  deaths;  and  include 
in  their  scope  26  states  and  i  district,  viz  :  Alabama  17,  California  3,  North  Caro- 
lina I,  South  Carolina  4,  Colorado  i,  Connecticut  4,  Georgia  5,  Illinois  34,  Indiana 
8,  Kentucky  16,  Louisiana  3,  Maine  3,  Maryland  17,  Massachusetts  51,  Michigan  8, 
Minnesota  5,  Missouri  95,  Mississippi  7,  New  Jersey  2,  New  York  432;  Ohio  14, 
Pennsylvania  88,  Tennessee  5,  Texas  25,  Vermont  3,  Virginia  6,  District  of  Columbia 
I,  and  unkiiou'ii  slates  5." 

From  a  later  article  by  the  same  author  (Annals  of  Anatomy  and  Surgery,  1881 : 

"The  total  number  of  tracheotomies  for  croup  in  the  United  States  collated  by  me 
to  date  comprises  903  operations  with  195  recoveries  and  708  deaths  ;  but  of  that 
number  there  were  found  43  operations  in  which  death  was  attended  by  such  compli- 
cations as  to  justify  their  exclusion  from  the  general  list,  and  hence  the  true  figures 
should  read — whole  number  operations,  860 ;  cures,  195,  and  deaths,  665,  or  i  cure 
in  a  little  over,  every  41/2  operations  (22.67  percent)." 


476 


DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 


The  following  is  a  list  of  the  operations  reported  by  me  in   the    State    of  Illinois 
(Annals  of  Anatomy  and  Surgery,  April,  1881). 


OPERATORS. 

OPERA- 
TIONS. 

RECOV- 
ERIES. 

OPERATORS. 

OPERA- 
TIONS. 

RECOV- 
ERIES. 

Dr.  E.  Andrews, 

I 

0 

Dr.  R.  S.  Cowan, 

3 

I 

Dr.  A.  T.  Bartlett, 

I 

0 

Dr.  F.  B.  Crummer, 

I 

0 

Dr.  F.  H.  Blackman, 

2 

I 

Dr.  H.  W.  Chapman, 

I 

0 

Dr.  R,  G.  Bogue, 

21 

6 

Dr.  W.  C.  Day, 

I 

0 

Dr.  F.  Brendel, 

I 

I 

Dr.  C.  W.  Earl, 

2 

0 

Dr.  Ferd  Brother, 

3 

0 

Dr.  J.  G,  Erhardt, 

5 

2 

Dr.  W.  A.  Byrd, 

2 

0 

Dr.  Christian  Fenger, 

6 

2 

Dr.  L.  Bremer, 

I 

I 

Dr.  H.  Z.  Gill, 

4 

3 

Dr.  W.  S.  Caldwell, 

I 

0 

Dr.  D.  W.  Graham, 

I 

0 

Dr.  F.  M.  Casal, 

I 

0 

Dr.  E.  L.  Harriott, 

I 

0 

Dr.  W.  J.  Chenoweth, 

I 

0 

Dr.  E.  F.  Ingals, 

3 

I 

Dr.  T.  A.  CoUett, 

4 

0 

Dr.  H.  A.  Johnson, 

21 

6 

Dr.  E.  P.  Cook, 

3 

0 

Dr.  W.  H.  KendaU, 

2 

0 

Dr.  F.  Koeberlin, 

I 

I 

Dr.  C.  T.  Parkes, 

I 

I 

Dr.  G.  W.  Lasher, 

2 

I 

Dr.  J.  P.  McClanahan, 

I 

0 

Dr.  — .  Ledlie, 

I 

I 

Dr.  A.  B.  Strong, 

I 

0 

Dr.  E.  W.  Lee. 

32 

8 

Dr.  J.  L.  White, 

I 

0 

Dr.  L.  A.  Mease, 

2 

I 

Dr.  H.  Wardner, 

3 

I 

D.  J.  P.  Mathews, 

I 

0 

Dr.  T.  Winston, 

I 

0 

Dr.  E.  W.  Mills, 

2 
I 

0 
0 

Dr.  John  Wright, 

I 

0 

Dr.  J.  W.  Newcomer, 

Dr.  James  Phillips, 

I 

0 

151 

38 

Dr.  D.  Prince, 

6 

0 

25V6  per 

cent. 

Since  the  above  list  was  published,  1881,  the  following  operators  have  added  to 
the  number  of  their  cases,  with  the  following  results  :  Dr.  W.  A.  Byrd,  7  cases,  re- 
covered, o  ;  Dr.  Bogue,  9,  recoveries,  3;  Dr.  Gill,  2,  recoveries,  o;  Dr.  Ingals,  10  or 
12  cases,  recoveries,  3.     Some  of  the  other  operators  report  "no  more  cases." 


SURGICAL  TREATMENT. 
SUMMARY  OF  TRACHEOTOMY  IN  ILLINOIS. 


477 


Length    of   time  the  patients  had 
been  sick  before  the  operation. 

TIME.  CASES. 

2  days  or  less,  -        -        -  g 

3  days         -        -        -       •        -  i6 

4  days      -----  21 

5  days 5 

6  days      -----  5 

7  days  -----  6 

8  days  -----  7 
10  days  -----  10 
14  days    -----  4 

Total  reported         -        -        -  82 


AGES. 

CASES 

Under  2  years 

-        -        - 

II 

2  to  3  years 

- 

14 

3  to  4  years      - 

.        -        - 

25 

4  to  5  years 

- 

20 

5  to  6  years 

- 

15 

6  to  7  years 

- 

5 

7  to  8  years 

- 

6 

8  to  9  years 

- 

8 

10  to  II  years 

- 

3 

12  to  20  years 

. 

2 

Over  20  years    • 

- 

I 

Total 
Age  of  I  not  given. 


Dates   at  Which  the  Patients  Died   After  the  Operations,  so  far  as 

Reported. 


Within  12  hours  (including  those  dying       i  Sixth  day 
immediately)  -         -         -         16! 

Seventh  day 
From  12  to  24  hours  -        -        -     19 


From  24  to  48  hours 
Third  day 
Fourth  diy     - 
Fifth  day 


Tenth  day 
Sixteenth  day     - 

Total  reported 


I 

2 
I 
I 

77 


4/8  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

THE  TUBE  WAS  PERMANENTLY  REMOVED  AS  FOLLOWS: 


DAY.  NO  OF  CASES. 

4th I 

5th 2 

6th- 7 

7th 2 

Sth 2       ' 

9th I 

loth  ------  2 

nth  -        -        -        -        -        -  2 

1 2th  -        -        -        -        .        -  I 


DAY,  NO.  Of  CASES 

14th      ------  I 

l6th  ------     I 

2ISt        ------  I 

44th         ------    I 

I20th  -----  2 

128th      ------    I 

Total  re[joited  -        -        -       27 

In  one  case  the  tube  still  remains. 
The  remaining  cases  are   not  reported   as 
to  this  item. 


PROBABLE  IMMEDIATE  CAUSE  OF  DEATH. 

I.  Lung  Complications. — 

1.  Pneumonia  or  broncho-pneumonia,        -----        28 

2.  Accumulation  of  membrane  and  mucus  in  the  trachea  and  bronchi,  10 

3.  Asphyxia  (seat  or  mechanism  of  which  not  given,  "        "  5 

II.  Erysipelas  and  oedema. —  ----__.        _i 

III.  Insufficient  after-treatment. — 

1.  Dried  and  hardened  accumulations  around  the  end  of  the  outer 

tube,  forming  a  cap,     --------  i 

2.  Other  causes,      ----------2 

IV.  General  Effects. — 

1.  Exhaustion  or  blood  poisoning,      ------         ig 

2.  Syncope,  ----------4 

3.  Collapse,  "possibly  hastened  by  haemorrhage"        -        -        -  i 

V.  Immediate  death  (cause  not  given),  ------       i 

Total,  --         -!----_--        72 

Other  Incidents. — 

Artificial  respiration  required  at  the  time  of  the  operation  (all  re- 
covered), ------___-j 

Complicated  with  whooping-cough  (died),  -        -        -        -  i 

Defective  tubes  (all  died),      --------3 

Retention  of  the  tube  over  30  days. — 

1.  From  exuberant  granulations,  ------     3 

2.  From  other  causes,         ---.«...         2 


SURGICAL  TREATMENT. 


479 


Operators.  Cases. 
A.  Jacobi,'  New  York,  about  450  cases  ;  formerly 

70%,  lately  15%  recoveries. 

L.  S.  Pilcher,!  Brooklyn.  (Of  the  first  20,  10  recov-  44 

eries  ;  of  the  last  24,  4  recoveries.) 

John  H.  Ripley,!  N.  Y., 89 

John  T.  Hodgen,!  St.  Louis,           -        -        -        -  92 

H.  H.  Mudd,i  St.  Louis, 41 

Harvy  G.  Mudd,'  St.  Louis 5 

Geo.  W.  Gay,'  Boston, 86 

City  Hospital,  Boston,            -----  206 

Daniel  Ayers,  Brooklyn,         -----  20 

J.  Pancoast,   --------  9 

Henry  O.  Marcy,'  Boston,      -----  62 

Cheever,  to  1874,  Boston,       -----  9 

Buck,   New  York,    (Cohen)            -        -        -        -  2 

Minor,              "              «-_--.  6 

C.  K.  Briddon  "             " 5 

Voss,                  "             ------  43 

Krakowitzer,    "             "----"  55 

Von  Roth          «            « 48 

D.  C.  Cocks,^    "            - 15 

John  H.  Packard,!  Philadelphia,    -        -        -        -  10 

Hodge,    Maslin,     -        -        -        -        -        -        -  il 

Drysdale,      "          -------  9 

R.J.  Levis,  "  -------17 


Recoveries. 


14 


29 
15 

9 

2 

29 

6S 

4 

4 

8 

6 

2 

2 

(one  an  adult)  o 

10 

16 

II 

8 

I 

2 

3 
2 


The  following  table  from  Dr.  Ripley  is  of  too  much  interest 
to  be  omitted : 


1  Letter  from  the  operator. 
*Archi v.  of  Pediatrics.     VoL  L 


No.  I. 


48o 


DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 


Age. 

^ 

1 

^ 

1 

.5 
s. 

r 

.<3 

1 

•S  ^ 

<4 

Up  to  I  year, 

5 

I 

I 

— 

I 

5 

Between  i  and  2  years, 

5 

6 

— 

— 

— 

II 

Between  2  and  3  years. 

7 

8 

4 

4 

8 

7 

Between  3  and  5  years, 

20 

12 

9 

4 

13 

19 

Between  <;  and  7  years. 

12 

8 

4 

I 

5 

15 

Between  7  and  9  years. 

I 

3 

— 

2 

2 

2 

At  17  years, 

I 

— 

— 

— 

— 

I 

51 

38 

18 

II 

29 

60=89 

Causes  of  Death. 

Bronchial    croup  ---.---.-36 

Erysipelas  and  bronchial  croup         -------i 

Toxsemia      ----_----..        6 

Anaemia  -        -        -         -         -         -        -        -        -        -        -4 

Respiratory  paralysis  and  ar.,x:iiia         -.--..         2 
Respiratory  paralysis         -------.-2 

Cardiac  paralysis  ----.-...j 

Pneumonia       -----__.        ___i 

Gangrene  of  wound      ------,.-.         i 

Accidental  plugging  of  tube      ----_._  ^ 

Acute  tuberculosis         ------.        __i 

Total  -._-.....  60 

The  following  list,  by  Dr.  Joseph  Winters,  kindly  furnished  by  him,  and  cor- 
rected at  my  request,  gives  the  largest  number  of  recoveries  after  tracheotomy  for 
croup  on  record,  in  children  under  one  year  of  age. 


SURGICAL    TREATMENT. 


481 


SUCCESSFUL     TRACHEOTOMIES     FOR   CROUP    IN  CHILDREN  ONE 
YEAR  OF  AGE  AND  UNDER. 


Case. 

Age. 

Disease. 

Operator. 

Authority. 

I 
2 

Weeks. 
6 

Months. 
3 

Croup. 
Croup. 

Scoutetten  (1830). 
Annandale.^ 

Soc.  Med.    des    Hop.  de 
Paris,  1867. 

Ed.  Med.  Jour.,  vol.   vii., 
part  2,   June,    1862,   p. 
1121. 

3 

6 

Croup. 

Kiister. 

Elias,  Deutsche  Med. 
Wochen.,  Nov.  9,  1S78, 
P-  555- 

4 

6V2 

Croup. 

Jos.  Bell. 

Bell :  Letter  to  Brit.  Med. 
Jour.  April  8,  1871. 

5 

7 

Croup. 

Tait. 

Brit.  Med.  Jour., April  15, 
1871,  p.  391. 

6 
7 

7 
7 

Croup. 
Croup. 

•  Lindner. 

Deutsche  Zeitschrift  f. 
Chir.,  Band  xvii.,   Heft. 

5  und  6. 

8 

7 

Croup. 

Wegner. 

Kronlein:  Archiv.  f.  klin. 
Chir.,  vol.  xxi.,  1877,  ?• 
266. 

9 

7 

Croup. 

Kronlein. 

Rauchfuss  in  Gerhardt's 
Handb.  Kind.,  vol.  iii., 
p.  202. 

7 

Croup. 

.._5 

Elias,  op.  cit.  from  St. 
Petersburg  Med.  Zeil- 
ung,  1877. 

II 

7V2 

Croup. 

Jos.  Bell.» 

Syme:  Ed.  Med.  Jour., 
vol.  vi.  part  2,  April, 
1 86 1,  p.  956. 

12 

8-V3 

Croup. 

Elias. 

Deutsche  Med.  Wochen., 
November  9,  1878. 

'  Child  lived  seven  weeks  after  the  operation.  On  autopsy  lungs  vv-ere  found  to  be 
perfectly  healthy. 

^Name  not  given. 

'Communication  to  Med.  Chirurg.  Soc,  Edinburgh.  Professor  Syme  thought 
that  the  operation  would  not  do  any  good  in  this  case,  but  yielded  to  Bell,  the 
house-surgeon,  who  did  the  tracheotomy,  which  was  followed  by  instant  relief  to  the 
child. 


482  DIPHTHERIA,  CROUP    AND    TRACHEOTOMY. 

Successful  Tracheotomies  for  Croup  in  Children. 


Case. 

^^<r. 

Disease, 

Operator. 

Authority. 

13 

10 

Croup. 

Day. 

Greenfield  in  St.  Thomas' 
Ilosp.  Rep., vol.  viii.,  p. 
263. 

14 

10 

Croup. 

Baizeau,* 

Gaz.  des  HSpitaux,  1867, 
P-  397- 

15 

10 

Croup. 

V.  Winiwarter,^ 

Jahrbuch  f.  Kind.,  3  u.  4, 
P-  337.  1876. 

16 

10 

Diphtheria. 

Elias, 

Deutsche  Med.  Woch. 
November  9,  1878. 

17 

10 

Croup. 

Bourdillat, 

L'Union  Med..  1872,  vol. 
xiii.,  3d  series,  p.  826. 

18 

II 

Croup. 

Geo.  F,  Shrady.8 

N.  Y.  Med.  Record,  vol. 
xxii.,  Nov.  4,  1882,  p. 
512. 

19 

II 

Croup. 

Trousseau. 

Paris  Theses,  1834,  t. 
cclxxviii ,  No.  289.P.13, 
Aussandon's  Thesis. 

20 

II 

Croup. 

Rauchfuss. 

Gerhardt's  Handb.  Kind. 
vol.  iii.,  p.  202. 

21 

II 

Croup. 

J.  Cooper  Forster. 

Brit.  Med.  Jour.,  March 
25.  1871,  p.  309. 

22 

II 

Croup. 

Derby. 

Stevens  :  Boston  Med.  & 
Surg,  lour.,  vol.  Ixxi., 
Oct.  1869,  p.  167. 

23 

12 

Croup. 

Lindner. 

Deutsche  Zeit.  f.  Chir., 
Band  xvii.,  Heft  5  u.  6. 

24 

12 

Croup. 

Trendelenburg. 

Gerhardt's  Hand.  Kind, 
vol.  vi.,  p.  262. 

25 

12 

Croup. 

A.  T.  Woodward. 

Mastin:  Gaillard's  Med. 
Jour.,  Jan.    1880,  p.  30. 

26 

12 

Croup. 

Dujardin. 

L'Union  Med.,  1872,  3d 
series,  vol.  xiv.,    p.    46. 

'Twelve  children  under  two  years  operated  on,  four  got  well. 

''Respiration  stopped  and  artificial  respiration  was  performed  for  ten  minutes,  and 
had  to  be  resorted  to  three  times  within  the  first  hour. 

^This  is  the  youngest  successful  case  operated  upon  in  this  country.  This  opera- 
tion was  performed  between  the  tenth  and  eleventh  month.     Child  is  still  living. 


SURGICAL    TREATMENT.  483 

Successful  Tracheotomies  for  Croup  in  Children  from  i  to  2  Years  of  Age. 


Case. 

Age. 

Disease. 

Operator. 

Authority. 

27 

Months. 
13 

Croup. 

Wardner. 

Gill:  111.  State  Med.  Soc. 

Trans.,  1878,  p.  164. 
Mastin  :  Gaillard's  Jour., 

January,  1880,  p.  30. 

28 

13 

Croup. 

Barthez. 

Gaz.  Hebdom.,  1862,  p. 
806. 

29 

13 

Croup. 

Trousseau.^ 

Jour,  des  Conn.  Med.- 
Chirurg.,  September  3, 
1834,  t  ii.,  p.  I. 

30 

13 

Croup. 

Archambault. 

Gaz,  des  H6pitaux,  1867, 
P-  307- 

31 

13 

Uiphiheria. 

Steavenson.2 

St.  Barthol.  Hosp  Re- 
ports, vol.  xviii,  1882, 
P-  313- 

32 

14 

Croup. 

Cabot* 

Haywood:  Boston  Med. 
and  Surg.  Jour.,  vol. 
Ixii.,  p.  273,  i860. 

33 

14 

Croup. 

V.  Langenbeck. 

Kronlein  :  Archiv.  f.  klin. 
Chi:,,  vol.  xxi.,  1877,  p. 
268. 

34 

14 

Croup. 

Rapin. 

Sanne:  Trait6  de  la  Diph  ■ 
therie,    p.     481,    Paris, 

1S77. 

35 

14V2 

Croup. 

Millard  et  H6mey. 

Sanne :  op.  cit,,  p,  481, 
Jour,  de  Therapeutique, 
1874. 

36 

15 

Croup. 

Cabot. 

Boston  Med.  and  Surg. 
Jour,,  vol.  Ixx.,  p.  61. 

37 

15 

Croup. 

H61ie. 

Gaz.  des  Hopitaux,  1867, 
P-397 

38 

15 

Croup. 

Baizeau. 

Gaz.  des  H6pitaux,p.  397, 
1867. 

39 

16 

Croup. 

Isambert 

Gaz.  des  H5p.,  1867,  p. 
307. 

'  Operation  same  year  as  reported. 

*  Child  had  scarlet  fever  and  recovered. 

*  Child  had  double  pneumonia  and  recovered. 


484  DIPHTHERIA,    CROUl'    AND    TRACHEOTOMY. 

Successful  Tracheotomies  for  Croup  in  Children. 


Case. 

Age. 

Disease. 

Operator. 

Authority. 

40 

16 

Croup. 

Lindner. 

Deutsche  Zeit.  f.  Chir., 
Band  xvii.,  Heft  5  u.  6. 

41 

16 

Croup. 

Wegner. 

Kronlein  ;  Archiv  f.  klin. 
Chir.,  vol.  xxi.,  1877. 

42 

17 

Croup. 

Nathan  Jacobson. 

N.  Y.  Med.  Record,  June 
30,  1883,  p.  705. 

43 

17 

Croup. 

Vigla. 

Gaz.  des  Hopitaux,  1867, 
?•  307- 

44 

18 

Diphtheria. 

Bartscher. 

Deutsche  Med.  Wochen., 
18S0,  p.  29. 

45 
46 

47 

18 
18 
18 

Croup. 
Croup. 
Croup. 

-C  Wiihusen.i 

Dub.  Med.  Press,  April  5, 
1865,  p.  320,froin  Uges- 
krift  for  Larger,  March 
16,  1865. 

48 

18 

Diphtheria. 

Josef  Pauley. 

Berlin,  klin.  Wochen- 
schrift,  February  25, 
1878,  p.  105-6. 

49 

18 

Croup. 

George  Rachel. 

Amer.  Jour.  Med.  Sci- 
ences, July,  1S77,  p. 95. 

50 

18 

Croup. 

Collins. 

Mastin.  Gaillard's  Med. 
Jour.,  vol.  Nxix.,  p.  30, 
January,   iSSo. 

51 

18 

Diphtheria. 

Voigt. 

Jahrbuch  f.  Kind.,  vol. 
viii.,  p   121,  1882. 

52 

18 

Croup. 

Moutard-Martin. 

Gaz.  des  Hop.,  1867,  p. 
308. 

53 

18 

Croup. 

Potain. 

Gaz.  des  Hop.,  1867,  p. 
308. 

54 

18 

Croup. 

Archambault. 

Gaz.  des  Hop.,  1S67,  p. 
307- 

55 

19 

Croup. 

Roger. 

Gaz.  des  Hop.,  1867,  p. 
30S. 

56 

19 

Croup. 

Pan  coast. 

Meigs  :  Amer.  Jour.  Med. 
Sciences,  April,  1849. 

57 

19 

Croup. 

Bose. 

Kronlein:  Op.  cit. 

'  One  case  died  on  eighty-first  day  of  exhaustion  from  tubercular  diarrhoea. 


SURGICAL    TREATMENT.  485 

Successful  Tracheotomies  for  Croup  in  Children. 


Case. 


5« 

59 
60 

61 

62 

63 

64 

65 
66 

67 


68 
69 

70 
71 

72 
73 


Months 
19 


19 
19 


19 


20 
21 


22 
22 


22 
22 


Disease. 


Croup. 

Croup. 
Croup. 

Croup. 

Croup. 

Croup. 

Croup. 

Croup. 
Croup. 

Diphtheria. 

Di[)h.  second- 
ary to  scarla- 
tina. 

Croup. 
Croup. 

Croup. 

Croup. 

Croup. 

Croup. 


Operator. 


Weber. 

Wegner. 
Trendelenburg. 

Jennings. 

Busch. 

Bose. 

Fitzau. 

Kronlein. 
T.  Sendler. 

House-surgeon' 

A.  J.  Walter. 

>■  Dower.  •< 

Isambert. 
Cushing. 

Laborde. 

Maslieurat-Lag6mard. 


Authority. 


Zeitschrift  f.  Ration.  Med. 
Neue  Folge  i,Band  iii., 
Heft  I,  p.  8,  1852. 

Kronlein .   Op.  cit. 

Vaneschi :  Berlin  klin. 
Wochen.,  April,  1872, 
p.  163. 

Archives  of  Pediatrics, 
vol.  i.,  No.  9,  Sept.  15, 
i884,p,  546. 

Vaneschi :  Berliner  klin. 
Woch.,  April,  1872,  p. 
163. 

Vaneschi .  Berliner  klin. 
Woch.,  April,  1872,  p. 
163. 

Berliner  klin.  Woch., 
April  25,  1S79,  p.  223. 

Kronlein:   Op.  cit. 

Vierteljahrschrift  f.  Prak. 
Heil.,  vol.  iv.,  p.  71. 

Poland,  Brit.  Med.  Jour., 
Sept.  16,  1882,  p.  523. 

R.  and  R.  J.  McCready, 
Am.  Jour.  Med.  Scien., 
1874. 

Brandt:  N.  Y.  Med.  Rec- 
ord, Jan.  13,  18S3,  p.  54. 

Sanne  :  Diph.,  p.  481. 

Pacific  Med.  and  Surg. 
Jour.,  vol.  vii.,  p.  14. 

Gaz.    Hebdom,    1862,  p. 

So  7. 

Gaz.  Med.  de  Paris.  1841, 
p.  380;  1842,  p.  170. 


^  Name  not  given. 


486  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

Successful  Tracheotomif.s  for  Croup  in  Children. 


Case. 

Age. 

Disease. 

Operator. 

Authority. 

74 

22 

Croup. 

Ferraux. 

Gaz.  Hebdom.  1862,  p. 
807. 

75 

22 

Croup. 

Johnson. 

111.  State  Med.  Soc. 
Trans.,  1879,  p.  120;  re- 
ported by  Gill. 

76 

22 

Croup. 

Wegner. 

Kronlein:  Op.  cit. 

77 

22 

Diphtheria. 

Mayer. 

N.  Y.  Med.  Record,  April 
26,  1884,  p.  457- 

78 

22 

Diphtheria. 

Parker. 

Steavenson,  St.  Barthol. 
Hosp.  Reports,  vol. 
xviii.,  1882,  p  323. 

79 

23 

Croup. 

Laborde. 

Gaz.  Hebdom.,  1862,  p. 
807. 

8o 

23 

I'roup. 

Trousseau. 

Sanne  ;  Diph.,  p.  481. 

8i 

23 

Croup. 

Bose. 

Kronlein :  Op.  cit. 

82 

23 

Croup. 

Burland. 

Gaz.  Hebd.,  1862,  p.  80S. 

Cases  Exact  Ages  not  Given. 

Years. 

83 

84 

8S 

-2 
1-2 

Croup. 
V  Croup. 

Krnckowizer. 
Korte,  three  cases. 

Jacobi :    Am.    Jour.  Ob. 
May,  1868. 

Arch,     fur     klin.      Chir 

86 

J 

Band  xxv.,  p.  820. 

87 
to 

1-2 

\  Croup. 

Revilliod,  six  cases.i 

L'Union  Med.,  3d  series 

93 

J 

L  xxii.,  1876,  p.  136. 

^Of  sixteen  children  operated  upon  under  two  years  of  age,  he  obtained  six  cures 
that  is  to  say,  37.5  per  cent  The  youngest  of  his  cases  was  fifteen  months,  the  old- 
est twenty-three  months. 

Monti,  Ueber  Croup  und  Diphtheritis,  pp.  309— 311,  has  reported  158  cases  of 
recovery  under  two  years  of  age,  in  1093  tracheotomies.  Eight  additional  cases  are, 
reported  by  Birnbaum.  Arch  f.  Chirurgie,  Bd.  31,  Hft.  2,  p.  346;  Ann.  of  Surg. 
Vol.  T..  p.  5S7. 


SURGICAL  TREATMENT.  487 

The  statistics  from  various  countries  demonstrate  to  us  but 
one  thing,  namel}',  the  benefit  of  tracheotomy;  but  now  to 
compare  tlie  results  obtained  in  different  countries  or  in  cer- 
tain regions  of  the  same  country,  we  must  not  be  dreaming. 
These  figures  give  only  the  statistics  in  totals,  but  they  con- 
tain elements  very  dissimilar. 

Thus,  as  Bartliez  has  clearly  shown,  the  statistics,  compiled 
with  the  object  of  demonstating  the  value  of  various  methods 
of  treatment  respectively  in  croup,  should,  to  be  decisive,  con- 
tain only  cases  perfectly  similar.  How  can  we  understand  the 
action  of  a  method  of  treatment  when  it  is  applied  in  one 
country  to  cases  of  simple  benign  diphtheria,  and  in  another 
to  the  infectious  or  malignant  form  of  the  disease  ?  When  we 
are  told  that  tracheotomy  succeeds  less  in  one  country  than  in 
another,  if  one  can  produce  in  support  of  the  assertion  only 
the  total  of  the  recoveries  or  their  proportion  to  the  number 
of  operations  in  each  place,  we  cannot  deduce  from  this  argu- 
ment any  legitimate  conclusion.  It  is  necessary  to  know 
whether  the  conditions  of  age  and  season  have  been  the  same, 
and  if  the  form  of  the  disease  has  been  similar,  and  whether 
the  treatment  has  been  applied  at  the  same  period  and  with 
the  same  care  in  one  case  as  in  the  other. 

This  information  not  being  furnished  by  any  of  the  statistics, 
we  must  abandon  a  comparison  of  the  results  from  different 
countries.  Let  us  content  ourselves  in  knowing  that  in  each 
tracheotomy  has  produced  signal  results. 

Some    of   the    Causes    which    Influence    the    Results  of 

Tracheotomy. 

Without  speaking  of  the  accidents  which  belong  to  the  op- 
eration itself,  nor  of  the  complications  which  supervene  after 
it,  several  causes  of  a  general  character  have  an  influence  on 
the  results  of  tracheotomy.  They  are  the  form  of  the  disease, 
the  age  of  the  patient,  and  the  season  of  the  year. 

Fat  III  of  the  disease. — Tracheotomy  is  not  a  method  of  treat- 
ment of  croup,  it  is  applied  entirely  to  the  laryngeal  obstruc- 


4^8  DIPHTHERIA,  CROUP  AND  TRACHEOTOMY. 

tion — the  cause  of  the  asphyxia.  This  obstacle  once  removed, 
the  diphtheria  runs  its  course  ;  if  it  is  benign,  the  asphyxia 
being  removed,  the  patient  recovers.  If  it  is  infectious  and 
mahgnant  the  patient  incurs  all  the  dangers  consequent  upon 
these  conditions  ;  he  may  succumb  to  the  general  poisoning  or 
to  a  renewal  of  the  asphyxia,  this  time  irremediable,  because 
produced  by  the  extension  of  the  false  membranes  to  the 
bronchi. 

The  infectious  forms  of  diphtheria  exercises  on  the  results  of 
tracheotomy  a  fatal  influence  so  well  demonstrated  that  it  con- 
stitutes the  principal  contra-indication  to  the  operation. 

Secondary  cro7ip  belonging  nearly  always  to  infectious  diph- 
theria, is  generally  unfavorable. 

■Age. — It  was  admitted  for  a  long  time,  on  the  testimony  of 
Trousseau,  that  tracheotomy  should  not  be  attempted  before 
the  age  of  two  years.  It  was  the  rule  not  to  operate  below 
that  limit,  and  still  less  below  twenty  months ;  failure  had 
always  followed  the  violation  of  this  precept.  The  statistics 
presented  in  1858  by  Roger  and  See,  proved  that  the  general 
average  of  recoveries  being  between  22  and  25  per  cent.,  there 
was  scarcely  one  per  cent,  below  two  years.  Being  presented 
before  the  Medicale  Societe  des  Hopitaux  of  Paris,  in  1867,  by 
Isambert,  on  the  occasion  of  a  tracheotomy  which  had  suc- 
ceeded in  a  child  of  sixteen  months,  this  question  called  forth 
a  discussion  resulting  in  the  proof  of  a  considerable  number  of 
recoveries  in  children  under  two  years.  Already  Scoutteten 
had  reported  the  history  (strongly  contested,  however,  as  to 
diagnosis,)  of  a  successful  case  of  tracheotomy  in  his  own 
daughter  of  six  weeks  of  age.  Barthez  had  announced  the  re- 
covery of  a  child  of  thirteen  months;  Trousseau  one  of  the 
same  age,  and  MasHeurat  Lagemard  that  of  a  child  of  twenty- 
three  months.  By  collecting  the  known  cases  in  France  and 
in  other  countries  we  can  present  the  following  table  : 

[See  the  later  list  by  Dr,  Winter's,  p.  481.] 

We  may  add  to  that  list  the  following :  the  case  of  a  child 
of  three  months  which  lived  six  weeks  after  the  operotion,  re- 
ported by  Dr.  Annandale  ;  one  of  sixteen  months   which  sur- 


SURGICAL  TREATMENT.  489 

vived  four  weeks  and  died  of  broncho-pneumonia,  reported  by 
Potain ;  one  from  Millard  of  eighteen  months,  operated  on  at 
Necker  Hospital  by  Collin  (1857),  and  that  lived  to  the  twen- 
fifth  day  ;  and  finally  one  of  twenty  months  operated  on  at 
Lille  by  Dujardin  that  lived  to  the  twenty-third  day.  These 
recoveries,  complete  or  incomplete,  should  evidently  be  taken 
only  as  exceptions,  but  they  show  that  if  recovery  at  this  age 
is  more  rare,  it  is  nevertheless  not  impossible.  They  did  not, 
however,  prevent  an  English  author,  Vincent  Jackson,  from 
condemning  the  operation  of  tracheotomy  in  children  under 
four  years  of  age.  The  facts  can  answer  this  evidently  exag- 
gerated assertion.  The  rarity  of  recoveries  under  two  years 
depends  upon  several  causes.  The  operation  is  much  more 
difficult,  because  of  the  shortness  of  the  neck,  its  plumpness  or 
fat,  and  the  mobility  and  flaccidity  of  the  trachea.  Now,  while 
tracheotomy  well  performed  is  not  a  dangerous  operation,  we 
must  admit  that  at  this  age  the  accidents  of  the  operation  are 
much  more  common.  The  comparatively  slight  physical  en- 
durance of  the  patients,  their  intractability,  the  difficulty  of 
nourishing  them,  the  increased  chances  of  their  contracting 
eruptive  fevers  after  the  operation,  are  so  many  obstacles  to 
success.  Research  has  been  made  equally  as  to  whether,  be- 
yond certain  limits  of  age,  tracheotomy  was  unfavorably  in- 
fluenced. The  age  of  seven  or  eight  years  has  been  consid- 
ered the  limit  at  which  this  operation  might  be  performed.  In 
support  of  this,  references  have  been  made  to  cases  at  St. 
St.  George's  Hospital,  and  to  others  reported  by  Billroth  and 
Wilms.  Beginning  in  1858,  Millard,  and  in  1867  Archambault 
and  Roger  opposed  this  view  of  the  case,  because  of  its  resting 
on  facts  not  sufficiently  numerous,  while  it  was  known  that 
numerous  recoveries  were  proved  to  exist  at  that  age. 

It  is  certain,  however,  that  failures  are  constantly  occurring 
in  tracheotomy  of  the  adult.  I  know  of  but  one  case  of  recov- 
ery at  this  period  of  life.  That  was  a  patient  of  Legroux  op- 
erated on  by  Robert  in  1858.  This  man,  aged  forty-seven 
years,  a  copper-smith,  presented  the  peculiarity  of  having  his 
trachea  ossified,  so  that  it  was  necessary  to  use  a  strong  pair 
of  scissors  to  divide  the  osseous  ring's. 


490 


DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 


The  following  is  a  list  of  tracheotomies  in  the  adult  of  which 
the  results  are  known  : 


Operators. 

Number  of 
Tracheotomies. 

Recoveries. 

Deaths 

Legroux, 

I 

I 

0 

Thierry, 

3 

0 

Archanibault, 

2 

0 

Burow, 

I 

0 

Billroth, 

I 

0 

Molendzinski, 

I 

0 

Hulke, 

I 

0 

Boiling, 

I 

0 

Briddon, 

I 

0 

Simon, 

I 

0 

Total, 

13 

I 

12 

[Ferd.  Brother, 

I 

I] 

[Cases  of  successful  tracheotomy  for  croup  in  adults  : 

Age. 
Legroux  (operated  by  Robert,  1858),  Sanne,       -      47 
Wm.  Wallace  (Brooklyn),  Mastin,  -         -  52 

D.  Hayes  Agnew  (Philadelphia),   Mastin,  -       35 

Cohen  reports  two  English  and  one  German=3.  Internat. 
Ency.  of  Surg.     Vol.  V.] 

Trousseau  gave  a  very  plausible  reason  for  these  unfortu- 
nate results.  The  large  dimensions  of  the  larynx  at  that  age, 
and  the  existence  of  the  inter-arytenoidian  glottis  leave  a  pas- 
sage for  the  air  sufficient  for  respiration  even  when  the  false 
membranes  have  diminished  the  caliber  of  the  organ.  As- 
phyxia is  only  produced  when  the  bronchi  become  in  their 
turn  invaded.  We  can  understand,  then,  how  tracheotomy 
fails. 

After  having  established  the  rarity  of  the  recoveries  as  well 
in  early  infancy  as  in  adult  age,  let  us  ascertain  what  period  of 
life  offers  the  greatest  advantages  for  the  success  of  the  opera- 


SURGICAL    TREATMENT.  49 1 

tion.  According  to  Millard,  ceteris  paribus,  the  chances  of  suc- 
cess are  in  direct  proportion  to  the  age  of  the  children.  Peter 
is  of  the  same  opinion.  Bourdillat  has  presented  the  following 
table. 

Under  2  years,  average  of  recoveries,        -        3  in  lOO 

At  2  years,            -  -         -         -         -            12  in  lOO 

From  272  to  3  years,  -         -         -         -      17  in  100 

From  3Y2  to  4  years,  -         -         -           30  in  1 00 

From  4'/2  to  5  \'ears,  -         -         -         -      35  in  ] 00 

From  572  to  6  years,  -         -         -           38  in  lOO 

Over  6  years,             -  -         -         -         -      41  in  lOO 

Dr.  Jacobi,  of  New  York,  having  obtained  13  recoveries  in 
67  cases  tabulates  them  as  follows : 

In  5  operations,  from  272  to  3  yrs.,  i,  that  is  20  in  100 
In  16  operations,  from  3  to  4  yrs.,  3,  that  is  16  in  lOO 
In  23  operations,  from  4  to  5  yrs.,  7,  that  is  30  in  lOO 
In  7  operations,  from  5  to  6  yrs.,  2.     that  is  28  in  100 

The  proportion  is,  therefore,  about  the  same.  Dr.  Bartels 
gave  a  table  also  concerning  the  influence  of  ages,  in  the  sta- 
tistics of  the  operations  performed  at  Berlin  in  the  service  of 
Prof.  Wilms,  as  follows  : 


Age. 
Up  to  2  yrs., 
Between  2  and  3  yrs.. 
Between  3  and  4  yrs.. 
Between  4  and  5  yrs.. 
Between  5  and  6  yrs., 
Between  6  and  7  yrs., 
Between  7  and  8  yrs., 
Between  8  and  14  yrs., 


Total,         -         -  335  103  37.5 


Number  of 
Tracheotomies. 

Recoveries. 

Proportion 
to  the  100. 

6 

0 

— 

56 

15 

26 

69 

22 

31 

74 

18 

24 

57 

20 

35 

33 

15 

45 

21 

5 

23 

19 

8 

49 

492  DIPHTHERIA,  CROUP   AND  TR 

An  anolagous  table  has  been  made  at  Paris  for  the  Hbpital 
des  Eufants,  from  1858  to  1861.     The  results  are: 


I 


Age. 

Number  of 
Tracheotomies. 

Recoveries. 

Proportion 
to  the  100. 

From  I  to  2  yrs., 

10 

I 

10 

From  3  to  5  yrs., 
From  6  to  10  yrs.,     - 

359 
122 

68 
68 

18 

55 

From  II  to  15  yrs., 

3 

— 

— 

Number  of 
TrachcoUnnies. 

Recoveries. 

Proportion 
to  the  100. 

653 

88 

13.62 

1298 

285 

21.9s 

335 

127 

37-89 

I  have  done  the  same  for  all  the  croup  cases  operated  on  at 
Sainte-Eiigenie  : 

Age, 
From  I  to  2  yrs., 
From  3  to  5  yrs., 
From  6  to  10  yrs.,     - 
From  II  to  15  yrs.,  26  9  32.30 

In  these  different  series  the  figures  lead  to  the  same  conclu- 
sion. The  recoveries  increase  in  proportion  to  the  age  of  the 
patient. 

However,  the  statistics  of  the  Sainte-Eugenie  show  that  the 
proportion  of  recoveries  is  a  little  lower  from  ii  to  15  years 
than  from  6  to   10. 

Sex. — It  has  been  observed  at  certain  periods,  that  the  re- 
sults of  tracheotomy  appeared  to  vary  according  to  the  sex  of 
the  patient.  The  recoveries  were  more  numerous  at  one  time 
with  the  boys,  at  another  with  the  girls.  Physicians  who  ob- 
served these  series  were  led  to  consider  success  as  favoring  one 
sex  to  the  disadvantage  of  the  other.  A  favoring  influence 
was  attributed  at  one  time  to  the  male,  and  at  another  to  the 
female  sex.  We  are  now  in  accord  that  sex  exercises  as  little 
influence  upon  the  results  of  tracheotomy  as  upon  the  etiology 
of  diphtheria.  The  real  obstacles  to  be  surmounted  in  the  cure 
of  croup  are  numerous  enough  without  creating  any  from  the 
imagination. 


SURGICAL    TREATMENT. 


493 


Tempef  anient. — It  is  fully  proven  that  vigorous  children  better 
support  the  depressant  and  anaemiant  action  of  diphtheria, 
as  well  as  the  injury  of  the  operation.  But  this  condition  is 
not  invariable ;  we  see  scrofulous,  puny  subjects  attain  re- 
covery. 

Previous  Health. — Certain  diseases,  I  mean  the  eruptive 
fevers  and  typhoid  fever,  exercise  a  considerable  influence 
upon  the  development  of  croup.  In  fact  if  these  diseases  are 
so  recent  that  the  croup  may  be  considered  as  secondary,  most 
frequently  the  infectious  element  assumes  an  important  rela- 
lation.  The  prognosis  is  narrowed  down  to  the  point  that  the 
operation  was  refused  for  a  long  time,  and  is  still  often  refused 
in  secondary  croup,  especially  that  which  follows  measles. 

When,  on  the  contrary,  the  commencement  of  diphtheria 
has  been  preceded  by  the  eruptive  fevers  by  a  considerable  in- 
terval of  time,  the  situation  may  be  considered  as  better.  In 
all  probability  these  exanthemata  will  not  intervene  after  tra- 
cheotomy ;  i«i  that  way  the  patient  will  escape  one  of  the  most 
formidable  causes  of  death.  As  to  other  diseases  which  pre- 
cede croup  so  closely  that  it  may  be  considered  secondary 
to  them,  viz.,  typhoid  fever,  whooping-cough,  various  cachexise, 
and  tuberculosis  in  particular ;  all  these  contingencies  consid- 
erably diminish  the  chances  of  success.  On  this  point  one  may 
refer  to  the  chapter  on  secondary  diphtheria. 

Among  the  preceding  diseases  we  must  also  place  croup.  It 
is  well  known  that  this  disease  does  return.  It  has  in  several 
cases  required  the  performance  of  a  second  operation  of  tra- 
cheotomy in  subjects  operated  on  the  first  time  for  the  same 
cause.  These  are,  however,  very  rare  cases.  They  are  far 
from  having  the  gravity  that  one  might  suppose.  Of  five  cases 
reported  by  Millard  one  only  succumbed.  Perier  recently 
cited  the  history  of  a  child  operated  on,  twice  tracheotomized 
within  one  month's  interval,  and  which  he  had  the  good  fortune 
to  cure.  As  to  the  operation  itself  this  repetition  may  be  a 
fortunate  circumstance.  The  cicatricial  connection  uniting  the 
skin  and  the  trachea,  serves  as  a  certain  guide  and  greatly  fa- 
cilitates the  operative  procedure.      Among  the    other   diseases 


494  DIPHTHERIA,    CROUP    AND    TRACHKOTOMY. 

which  may  have  a  favorable  influence  when  they  precede 
croup,  chronic  bronchitis  and  whooping-cough  have  been  men- 
tioned (Guersant,  Cook,  Millard).  An  habitual  cough,  con- 
tracted by  the  patient  a  long  time  previously,  is  supposed  to 
facilitate  the  detachment  of  the  false  membranes.  Of  eighteen 
cases  of  diphtheria  consecutive  to  this  disease,  twelve  termi- 
nated fatally. 

Social  Conditions, — It  is  understood  that  children  whose 
parents  are  well-to-do  are  in  better  condition  than  others  ;  the 
diet  and  care  in  every  respect  are  not  wanting. 

Treatment  in  the  family  offers  great  advantages  when  it  can 
unite  all  the  needed  resources ;  moreover,  in  avoiding  the  stay 
at  hospital  the  patient  escapes  the  contagious  diseases  which 
act  in  such  a  fatal  manner  on  the  case. 

Previotis  Treatment. — In  speaking  of  the  medical  treatment 
I  have  shown  the  necessity  of  being  sparing  in  the  use  of  the 
means  at  our  disposal. 

Tracheotomy  has  the  best  chances  to  succeed,  said  Trousseau, 
uninfluenced  by  all  previous  treatment.  Without  going  so  far, 
one  may  follow  the  course  that  I  have  indicated.  The  patients 
that  we  subject  to  tracheotomy,  depressed  by  emetics  too  fre- 
quently repeated,  by  cauterization,  by  the  struggles  and  suf- 
fering, are  in  a  most  unfavorable  condition. 

Season  of  the  year. — According  to  Fischer  and  Bricheteau, 
the  influence  of  season  upon  the  success  of  tracheotomy  is  re- 
markable. Winter  and  spring  periods  of  the  year  which  favor 
the  development  of  pneumonia  and  broncho-pneumonia,  are 
especially  unfavorable  ;  summer  and  autumn,  on  the  contrary, 
are  propitious  to  recovery. 

The  statement  of  all  the  tracheotomies  done  at  the  Sainte 
Eugenie  up  to  the  beginning  of  1876  has  given  me  the  best  re- 
sults for  June  and  for  August,  to-wit :  i  :  3.31  and  i  :  3.56  re- 
spectively. November,  December  and  January  give  1:7.19, 
6.18,  5.04  respectively. 

[See  also  the  large  table  of  cases,  p.  321-2.] 

Pulmonary  Injlatnmations. — It  is  by  these  that  a  large  num- 
ber of  the  patients  die  who  do  not  sink  under  the  diphtheritic 
infection. 


SURGICAL  TREATMENT.  495 

Broncho-pneumonia  is  the  scourge  of  the  tracheotomized, 
but  since  the  use  of  the  cravat  it  is  less  frequent,  without,  how- 
ever, ceasing  to  be  formidable. 

Eruptive  Fevers. — The  epidemic  condition  of  the  hospital 
wards  frequently  affects  the  convalescents  who  have  not  pre- 
viously had  these  diseases,  and  turns  to  failure  cases  which 
promised  success.  The  most  common  of  all.  measles,  is  par- 
ticularly dangerous  by  its  natural  tendency  to  become  com- 
plicated with  broncho-pneumonia,  a  tendencx'  which  finds  only 
too  great  a  facility  to  develop  itself  in  those  operated  on  for 
croup.  Scarlatina  sometimes  occasions  a  relapse  of  the  diph- 
theria, often  less  severe  than  the  former  attack.  Nevertheless 
it  is  dangerous  of  itself  because  of  the  soil  on  which  it  is  im- 
planted. Other  diseases,  such  as  typhoid  fever  and  variola, 
also  very  dangerous,  are  fortunately  more  rare. 

Indications  for  Tracheotomy. 

The  only  (unique)  indication  for  the  operation  is  asphyxia 
Agreement  has  always  prevailed  on  this  point.  Differences 
have  existed  solely  respecting  the  intensity  of  the  asphyxia. 
Some  have  recommended  surgical  intervention  during  the 
second  period,  while  asphyxia  is  still  intermittent.  Others 
have  preferred  to  wait  till  asphyxia  had  advanced  to  its  last 
degree,  viz.,  the  period  of  anaesthesia.  The  first  of  these  plans 
is  certainly  the  most  brilliant,  it  furnishes  numerous  recoveries, 
but  it  might  be  accused  of  causing  some  patients  to  be  oper- 
ated on  who  might  have  been  cured  by  medical    means    alone. 

The. second  is  dangerous,  exposing  the  patients  to  the  peril 
of  dying  without  the  operation,  and  may  also  let  them  reach 
such  a  state  of  depression  that  they  can  no  longer  react  after 
it,  and  thus  result  in  no  benefit. 

The  early  operation  was  recommended  by  Trousseau,  and  it 
remained  for  a  long  time  the  practice  at  the  hospital  in  rue  de 
Severes.  "  As  long  as  tracheotomy  was  in  my  hands  a  treach. 
erous  weapon,"  said  Trousseau  in  1834  and  in  185 1,  "  I  said, 
'  It  is  necessary  to  operate  as  late  as  possible  ;'    but   now   that 


49^  DIPHTHERIA,  CROUP  AM)  TRACHEOTOMY. 

I  can  count  numerous  recoveries  I  say,  '  It  is  neceessary  to  op- 
erate as  early  as  possible.'  "  Consequently,  subtracting  from 
this  proposition,  that  which  was  too  absolute,  he  modified  it 
as  follows :  "  The  earlier  the  operation  is  performed  the 
greater  are  the  chances  for  success." 

Millard,  who  fully  adopted  the  ideas  of  his  [teacher,  demon- 
strated by  actual  figures  that  tracheotomy  furnishes  results 
infinitely  better  when  it  is  practiced  in  the  second  period 
rather  than  in  the  third.  The  preference  shoulJ  not  always 
extend  to  exclusiveness.  Trousseau  says  farther :  "  When  the 
local  lesion  constitutes  the  principal  danger  of  the  disease, 
whatever  degree  the  asphxia  may  have  reached,  if  the  child 
has  but  a  few  minutes  to  live,  tracheotomy  succeeds  nearly  as 
well  as  if  it  had  been  done  three  or  four  hours  earlier."  How- 
ever true  in  the  main  this  remark  may  be  it  should  not  be 
taken  literally.  It  would  lead  directly  to  the  contrary  of  the 
first  proposition,  and  serve  as  an  argument  to  partisans  of  the 
late  operation. 

To  state  the  case  in  its  true  hght,  we  say :  Asphyxia,  to 
whatever  degree  it  may  have  advanced,  should  never  arrest 
the  hand  of  the  operator;  and,  as  long  as  tiie  patient  is  alive, 
it  is  a  duty  to  operate.  Therefore  it  is  very  different  from  sys- 
tematically letting  the  asphyxia  reach  an  advanced  degree. 
Whilst  recommending  tracheotomy  in  the  second  stage  of 
croup.  Trousseau  did  not,  therefore,  encounter  the  great  incon- 
veniences belonging  to  the  operation  i)i  extremis. 

The  good  results  which  early  tracheotomy  produces  should 
not  prevent  our  inquiring  whether  the  patient  might  not  ex- 
pect much  more  from  a  course  which  would  give  more  impor- 
tance to  temporization. 

Tracheotomy  is  the  supreme  therapeutic  measure  against 
croup ;   it  is,  however,  not  the  only  one. 

Trousseau,  who  did  not  believe  in  the  cure  of  croup  by 
means  aside  from  surgical  intervention,  acted  correctly  when 
he  sought,  first  of  all,  to  place  his  patients  in  the  most  favora- 
ble condition  for  a  fortunate  issue  of  the  operation.  This 
opinion,  too  exclusive,  has  found  opponents. 


SURGICAL    TREATMENT. 


497 


Barthez  has  demonstrated  that  croup  will  yield  to  medical 
means  to  an  extent  worthy  of  mention.  Taking  again  the  list 
of  all  the  croup  cases  entered  at  the  Sainte-Eugenie,  I  have 
reached  the  conclusion  that  in  2,809  cases,  204,  that  is,  i  in  13, 
have  been  restored  to  health  without  the  operation.  This  pro- 
portion, even  if  it  were  still  less,  requires  that  we  take  it  into 
consideration.  To  this  objection  it  has  been  answered  that 
tracheotomy,  properly  performed,  is  not  of  itself  dangerous  ; 
some  have  presented  the  harmlessness  of  this  operation  in  the 
case  of  chronic  or  acute  lesions  of  the  larynx,  other  than  diph- 
theria, and  in  that  of  foreign  bodies  in  the  air-passages.  Now, 
admitting,  if  we  will,  that  all  the  operators  are  equally  ex- 
perienced in  tracheotomy,  we  must  acknowledge  that  very 
grave  accidents  have  happened  in  the  ablest  hands,  such  as 
hiemorrhage,  syncope  and  asphyxia,  which  are  often  followed 
by  death.  We  may  add  thereto  the  influence  of  the  wound 
which,  in  the  very  young,  is  not  always  exempt  from  dangers,  as 
also  the  complications  arising  from  the  wound,  viz.,  gangrene, 
diphtheria,  erysipelas,  etc. 

If  then  the  cure  can  be  effected  by  means  which  avoid  the 
imminence  of  these  dangers,  no  valid  reason  would  justify  the 
neglect  of  their  employment.  Moreover,  why  operate  before 
the  patient  is  in  want  of  air  ? 

Tracheotomy  is  not  the  treatment  of  croup,  but  of  the  as- 
phyxia ;  it  is,  therefore,  only  applicable  at  a  time  when  the 
latter  is  continuous  and  not  at  the  time  when  relief  of  greater 
or  less  length  follows  each  paroxysm  of  suffocation.  However, 
from  the  moment  when  the  paroxysms  appear  the  patient 
should  be  closely  watched.  One  paroxysm  may  be  sufficiently 
severe  to  produce  death.  If  the  operator  is  within  reach,  he 
may  save  the  life  of  the  patient. 

Such  cases  are  unique,  when  asphyxia  alone  is  involved, 
which  authorize  the  performance  of  tracheotomy  during  the 
second    stage. 

We  rarely  find  such  a  case ;  therefore,  the  rule  still  holds  to 
commence  by  medical  treatment.  But,  having  thus  com- 
menced, it  should  be  followed  with  prudence ;  and,  while 
tracheotomy  should  not  be  precipitated,  we  must  be  careful  not 


498  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

to  postpone  it  too  long.  This  stumbling-block  has  not  been 
appreciated  by  those  who,  exaggerating  a  truly  wise  precept, 
have  extolled  beyond  measure  the  employment  of  medical 
means,  and  have  postponed  tracheotomy  to  the  advanced 
period  of  asphyxia. 

Tracheotomy,  practiced  in  extremis,  has  for  it  the  authority 
of  Archambault,  but  still  we  should  know  exactly  the  opinions 
of  this  able  physician.  The  recoveries  that  he  has  had  in  mori- 
bund patients,  have  taught  him  that  the  operation,  performed 
under  these  conditions,  does  not  always  involve  the  fatal  con- 
sequences which  he  had  at  first  dreaded.  He,  therefore,  ad- 
vises not  to  withdraw  from  the  operation  in  cases  where  the  in- 
tervention of  the  physician  has  been  asked  only  at  the  last 
stage ;  but,  as  to  advising  to  wait  till  that  time  to  decide,  he 
denies  it  most  emphatically.  Such  a  course  would  expose  to 
painful  disappointment.  The  decided  depression,  and  some- 
times a  condition  of  apparent  death  in  which  the  patient  is 
found,  not  only  does  not  permit  of  delay,  but  exposes  to  the 
gravest  accidents.  Supposing  the  operator  arrives  in  time, 
still  he  must  operate  rapidly.  From  this  alone,  the  position 
given  to  the  patient  during  the  operation  is  very  restraining  to 
the  respiration,  and  may  soon  cause  a  function  to  cease  which 
is  already  imperfectly  perforrned.  Should  now  difficulties  in 
the  operation  present  themselves,  its  performance  be  protracted 
and  difficult,  and  should  the  search  for  the  trachea  and  the  in 
cision  not  be  made  almost  in  the  same  moment,  the  patient  will 
sink.  This  is  one  of  the  most  frequent  modes  of  death  during  the 
operation.  In  other  cases  the  patient,  half  restored  at  the  mo- 
ment of  opening  the  trachea,  sinks  in  a  few  moments,  having  no 
longer  sufficient  strength  for  reaction. 

Duhomme,  on  the  authority  of  Claude  Bernard,  has  showed 
that  the  effects  of  asphyxia  are  much  less  disposed  to  disap 
pear  when  it  has  existed  a  longer  time.  It  vitiates  the  blood 
profoundly  and  even  when  air  is  supplied  freely  but  slowly, 
the  entire  economy  is  so  modified  by  the  incomplete  haematosis, 
that  it  is  often  found  in  a  condition  incapable  of  recovering. 
We  can  in  this  case  say  with  the  author,  Snblata  causa,  non 
tollitur  effectKs. 


SURGICAL  TREATMENT.  499 

When  asphyxia  alone  is  concerned,  the  dangers  of  prolonged 
delay  are  still  not  too  great,  as  the  recoveries  of  Archambault 
prove.  But  the  situation  is  different  when  to  the  dyspnoea  is 
added  a  profound  poisoning.  Completely  depressed  under  the 
influence  of  these  two  causes,  the  patients  operated  on  have  no 
longer  the  power  for  reaction.  Barthez  has  insisted  upon  this 
point ;  and  he  has  showed  that  these  children  make  no  effort 
to  expel  the  false  membranes ;  and  they  permit  in  the  bronchi 
and  in  the  canula,  the  accumulation  of  the  secreted  fluids  which 
dribble  from  the  orifice  of  the  tube,  and  they  progress  to  an- 
haematosia,  after  the  operation  the  same  as  before  it. 

To  wait  for  asphyxia  before  performing  tracheotomy  in  the 
case  of  profound  infection,  is  to  expose  this  operation  to  be- 
come wholly  illusory.  The  only  chance  for  recovery  is  in  re- 
moving one  of  the  two  factors  which  contribute  to  this  lamen- 
table situation.  Asphyxia  is  the  only  one  over  which  thera- 
peutics has  control ;  this  action  it  exercises  by  tracheotomy, 
provided,  always,  that  asphyxia  has  not  extended  too  far.  By 
operating  during  the  second  period,  before  the  asphyxia 
(I'anoxemie),  and  the  poisoning  have  united  their  action,  we 
have  many  chances  of  eliminating  the  former,  and  of  having 
only  the  latter  to  deal  with. 

hi  conclusion,  in  a  case  where  asphyxia  predominates,  it  is 
too  early  to  operate  in  the  second  period,  and  too  late,  very 
often,  in  the  third.  We  should,  therefore,  endeavor  during  the 
first  two  periods,  to  provide  for  recovery  by  medical  means 
If  they  produce  no  relief,  we  should  not  push  their  employ- 
ment beyond  the  second  period,  inasmuch  as  there  is  no  bene- 
fit from  them  during  the  third.  As  heretofore  stated,  trache- 
otomy is  so  much  the  more  successful  in  proportion  as  it  is 
performed  earlier  ;  so  by  uniting  the  two  indications,  we  decide 
to  perform  the  operation  at  the  end  of  the  second  period  or  at 
the  beginning  of  the  third,  at  the  moment  when  the  first  signs 
of  continued  asphyxia  appear.  When,  on  the  contrary, 
the  intoxication  is  the  predominant  symptom,  it  is  necessary  to 
operate  during  the  second  period.  Nearly  all  authors  are  in 
accord  with  this  precept  formulated  by  Barthez:     ''If  it  is  in- 


500  niPHTHEKIA,    CROUP    AND    TRACHEOTOMY. 

fectious  croup, it  is  preferable  to  operate  iu  the  second  period ;  if  it 
is  not  evidently  the  infectious  form,  it  is  proper  to  try  medical 
treatment  and  to  zvait  to  operate  till  the  end  of  tJie  second  period, 
especially  if  the  child  be  young." 

These  rules  are  applicable  in  the  majority  of  cases  ;  but  they 
have  exceptions.  The  violence  of  a  paroxysm  of  suffocation 
may  necessitate  the  performance  of  tracheotomy  in  the  middle 
of  the  second  period.  At  hospital  it  is  seldom  that  aid  cannot 
be  summoned  in  time.  In  the  practice  of  the  city  it  is  differ- 
ent. Whenever  it  is  possible  to  leave  with  the  patient  a  phy- 
sician experienced  in  tracheotomy,  it  is  indispensable  to  do  so 
in  order  to  avoid  being  taken  by  surprise.  When  this  resource 
fails,  it  is  wise  to  take  advantage  of  the  moment  when  the 
operator  and  his  assistants  are  present,  to  open  the  trachea,  as 
soon  as  the  paroxysms  are  seen  to  become  more  frequent  and 
more  severe ;  for,  when  once  separated,  who  knows  whether 
the  necessary  aid  can  be  reassembled  in  due  time.  It  has  hap- 
pened more  than  once  that  the  disease,  becoming  suddenly 
aggravated  when  least  expected,  has  taken  everybody  by  sur- 
prise, and  the  necessity  to  operate  occurred  in  the  absence  of 
the  physician.  Time  being  lost  in  hunting  him,  he  arrives  only 
in  time  to  witness  the  death,  A  hasty  operation,  perhaps, 
might  have  saved  the  patient.  Still  other  circumstances  au- 
thorize the  earlier  performance  of  the  operation.  It  is  always 
an  advantage  to  operate  by  daylight ;  artificial  light  serves  the 
purpose  imperfectly,  and  requires  an  additional  assistant.  If 
then,  a  little  while  before  evening  the  conviction  is  clear  that 
the  operation  will  become  necessary  during  the  evening  or 
during  the  night,  we  will  act  wisely  to  take  advantage  of  the 
sunlight. 

CONTRA-INDICATIONS. 

For  some  years  past  the  range  of  contra-indications  has  be- 
come perceptibly  restricted.  Trousseau  did  not  operate  on 
croup  secondary  to  measles  or  scarlatina.  Pseudo-membran- 
ous bronchitis,  broncho-pneumonia,  and  generalization  of  diph- 


SURGICAL    TREATMENT.  5OI 

theria  were  considered  as  so  many  invalidating    impediments. 

A  discussion  raised  at  the  session  of  the  "  Societe  Medicale 
des  Hopitaux"  in  1867,  in  which  Isambert,  Peter,  Archam- 
bault,  Roger,  Potain,  Moutard  Martin,  Vigla,  and  Dumont- 
pallier  participated,  showed  the  progress  made.  In  the  opin- 
ion of  these  eminent  physicians  there  does  not  exist  an  abso- 
lute contra-indication  to  tracheotomy.  Such  a  broad  concep- 
tion of  the  situation  is  perfectly  logical.  As  tracheotomy  has 
become  more  common  in  medical  practice,  some  of  the  bolder 
surgeons  have  operated  without  regarding  the  veto  offered  by 
their  predecessors.  Their  efforts  have  been  crowned  with  suc- 
cess ;  and  we  have  been  able  to  cure  patients  which  would  have 
been,  a  short  time  previously,  abandoned  as  incurable.  In  this 
way  croup  cases  have  been  cured  when  attacked  with  broncho- 
pneumonia, and  pseudo-membranous  bronchitis,  and  croup 
cases  following  measles  and  scarlatina. 

Psejido-membranons  bronchitis  was  considered  as  presenting 
a  formal  contra-indication  ;  but  first  of  all,  are  we  ever  quite 
sure  of  its  existence  ?  We  know  how  treacherous  are  the  signs 
furnished  by  auscultation  in  a  subject  attacked  by  croup.  The 
feebleness  of  the  vesicular  murmur  in  certain  parts  of  the  chest, 
the  presence  of  coarse  crepitation,  all  these  signs  and  many 
others  prove  nothing  absolutely.  The  frequence  of  the  respi- 
ration, beyond  fifty  in  the  minute,  the  slow  increase  of  the  as- 
phyxia, and  above  all,  the  cachectic  palor  of  the  surface  taking 
the  place  of  the  cyanosis  which  indicates  laryngeal  obstruction, 
can  furnish  only  presumptive  evidence  ;  they  indicate  a  pul- 
monary lesion  without  specifying  what  one.  The  only  symp- 
tom that  is  conclusive  is  the  expulsion  of  tubulated  or  ramified 
false  membranes  of  which  the  form  indicates  the  source  ;  we 
often  see  patients  expel  false  membranes  when  they  have  ex- 
hibited no  other  signs  attributable  to  the  pseudo-membranous 
bronchitis.  It  often  passes  unnoticed;  we  operate  on  our  patients 
without  suspecting  their  having  it.  Should  its  proof  stay  the 
hand  of  the  operator  ?  Certainly  not.  First,  because  the  ex- 
pulsion of  the  arborescent  fragments  gives  relief  to  the  patient, 
and  may  have  a  favorable   influence   upon  the    course    of  the 


502  DIPIIJIIERIA,  CROUP  AND  TRACHEOTOMY. 

disease.  Secondly,  Millard  and  Peter  report  cases  of  recovery 
by  tracheotomy  with  such  coincidence.  I  have  witnessed  my- 
self the  recovery  of  five  operated  cases  of  croup  which  had  ex- 
pelled this  variety  of  false  membrane.  In  others  I  have  seen 
death  occur  at  the  end  of  so  long  a  period,  a  month  for  exam- 
ple, that  the  pseudo-membranous  bronchitis  could  not  be  held 
responsible  for  this  termination.  The  extension  of  diphtheria 
to  the  bronchi,  is  not,  therefore,  a  contra-indication  againt 
tracheotomy  when  it  is  accompanied  by  symptoms,  indicating, 
at  the  same  time,  a  laryngeal  obstruction.  Surgical  interven- 
tion should  be  opposed  only  in  the  cases  in  which  there  is  an 
evident  predominence  of  asphyxia  from  the  lungs. 

BfoncJio-pneinnonia,  even  more  than  pseudo-membranous 
bronchitis,  has  been  dreaded  by  operators  and  has  been  placed 
among  the  positive  contra-indications.  Its  gravity  is  beyond 
question,  but  its  diagnosis  is  very  difficult  if  not  impossible. 

Auscultation  and  percussion  furnish  only  uncertain  results. 
The  only  symptoms  on  which  we  can  depend  are  the  extreme 
frequence  of  the  pulse  pointed  out  by  Archambault,  and  the 
acceleration  of  the  respiration  indicated  by  Barthez.  When- 
ever the  respirations  exceed  fifty  in  the  minute  there  is  in  all 
probability  pulmonary  inflammation.  Let  us  add  to  these 
signs  also  the  rise  in  the  temperature  in  the  body. 

Being  but  little  elevated  in  the  case  of  ordinary  diphtheria, 
when  inflammation  develops  it  rises  to  about  40°  (104°  F.). 
Notwithstanding  the  aid  that  these  facts  may  furnish  we  are 
still  generally  in  almost  complete  uncertainty.  However  grave 
may  be  the  prognosis  of  croup  when  broncho-pneumonia  su- 
pervenes, strictly  speaking,  the  diagnosis  does  not  interdict 
tracheotomy  ;  the  authors  I  have  mentioned  are  in  accord  upon 
this  point.  In  support  of  this  opinion  Peter  has  reported  the 
history  of  a  patient  of  Grisolle's  who  was  tracheotomized,  not- 
withstanding the  existence  of  a  clearly  established  broncho- 
pneumonia and  who  recovered.  Why,  indeed,  not  operate  ? 
One  says  because  these  cases  of  broncho-pneumonia  are 
always  fatal  from  the  beginning.  The  above  case  proves  the 
contrary  ;  but,  should  not  a  case  of  recovery  be  known,  still, 
the  refusal,  it  appears  to  me,  would  not  be  justified.     Respira- 


SURGICAL    TREATMENT.  5O3 

tion  through  the  tube,  says  one,  is  likely  to  engender  broncho- 
pneumonia or  to  aggravate  it  when  it  previously  exists.  If 
that  were  always  so  the  cases  of  broncho-pneumonia  which 
develop  after  the  operation  would  never  recover;  but  Millard, 
Archambault  and  Peter  have  cited  cases  of  recoveries  under 
similar  circumstances.  I  have  seen  five  cases  recover  in  which 
broncho-pneumonia  became  apparent  on  the  fifth  day  after  the 
operation.  Respiration  through  the  tube  is  not,  therefore,  posi- 
tively fatal  to  the  broncho-pneumonia,  especially  when  proper 
precautions  are  taken. 

Suppose,  on  the  other  hand,  a  patient  has  two  causes  of 
asphyxia,  to  wit :  a  lesion  of  the  larynx,  and  also  one  of  the 
lungs,  is  not  the  indication  clear  to  relieve  him  of  one,  the  ef- 
fects of  which  we  can  instantly  neutralize?  Broncho-pneumonia 
is,  therefore,  not  an  irreversible  contra-indication  of  tracheot- 
omy. 

Piieiwionia. — Lobar  inflammation  of  the  lungs  being  much 
more  rare  than  broncho-pneumonia,  we  have  seldom  occasion 
to  discuss  the  dangers  arising  therefrom  in  reference  to  the 
question  of  tracheotomy.  Guersant  was  far  from  considering 
it  as  a  positive  contra-indication.  He  reports  the  history  of 
two  tracheotomies  performed  by  his  son  in  two  cases  of  croup 
complicated  with  lobar  pneumonia.  Both  patients  survived  ; 
the  first  to  the  eighth  day,  the  second  to  the  fourteenth,  the 
wound  being  almost  cicatrised.  Millard  remarks  on  this  point 
that  there  does  not  exist  in  science  a  single  authentic  case  of 
complete  recovery  of  croup  complicated  with  veritable  pneu- 
monia at  the  time  of  the  operation.  I  am  prepared  to  cite  one. 
The  fact  is  all  the  more  interesting,  as  the  pneumonia  inter- 
vened three  times  during  the  course  of  the  same  attack  of 
croup. 


"A  girl  of  7  years  of  age  (J.  N.)  was  admitted  to  the  Sainte-Eug^nie  hospital,  ward 
Sainte-Mathilde.  No.  8,  December  6,  1865,  on  the  third  day  of  croup,  after  several 
attacks  of  suffocation,  and  was  at  the  time  in  the  midst  of  the  third  period;  retraction 
of  the  soft  parts  of  the  chest  {tirage)  considerable,  laryngeal  wheezing,  palor  with  a 
slight  cyanotic  tint;  voice  still  audible.  Nothing  in  the  throat;  no  submaxillary  en- 
gorgement 


504  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

Auscultation,  made  at  the  time  of  her  admission,  revealed  at  the  right  posterior 
summit  a  well  marked  bronchial  tone  of  the  respiration,  and  at  the  same  time  a  de- 
cided resonance  of  the  laryngeal  bruit.  Resonance  was  diminished  in  the  corres- 
ponding region.  Tracheotomy  was  performed  some  hours  after  admission,  and 
fragments  of  false  membranes  were  expelled  when  the  tube  was  introduced. 

Pneumonia  of  the  summit  of  the  right  lung  expressf  d  itself  more  clearly  the  follow- 
ing days,  and  the  respiration  assumed  the  cavernous  tone,  then  the  phenomena  di- 
minished and  the  pneumonia  improved  and  disappeared.  During  this  time  the 
croup  had  progressed  towards  recovery;  the  lube  was  removed  on  the  seventeenth 
■day;  cicitrazation  wes  completed  on  the  fortieth  day,  all  of  which  did  not  prevent  the 
reappearance  of  the  pneumonia  in  the  same  place  on  the  thirty-ninth  day,  and  again 
the  forty-sixth.  Recovery  was  complete  on  the  sixty-first  day." 

Secondary  Croup. — Measles  and  scarlatina  have  been  re- 
garded as  causing  cases  of  croup  always  to  be  fatal.  Trous- 
seau refused  to  operate  on  croup  cases  occurring  under  these 
conditions.  However,  Millard  cites  three  cases  of  success  ob- 
tained by  tracheotomy  in  rubeolar  croup.  I  am  in  posession 
of  four  observations  of  simlar  facts.  [Dr.  L.  S.  Pilcher  reports 
one.] 

Scarlatinous  croup,  which  Trousseau  and  Millard  consider 
as  still  more  grave,  tracheotomy  having  alwas  failed,  has  fur- 
nished me  also  four  cases  of  success 

It  is  different  with  small-pox.  The  general  adoption  of  vac- 
cination makes  this  form  of  croup  very  rare.  I  have  only 
known  of  two  cases  ;  both  terminated  fatally,  one  after  tra- 
cheotomy, the  other  without  the  operation. 

Diphtheria  which  follows  typJioid  fever  is  always  fearfully 
grave.  In  eight  cases  of  diphtheria  supervening  under  these 
conditions,  there  was  not  a  single  recovery  ;  the  tendency  to 
infection  and  generalization  was  extreme.  Of  this  number  a 
single  case  of  croup  presented  itself  which  could  be  operated 
on;  that  one  succumbed. 

Whooping-cough  does  not  seem  to  have  a  serious  influence 
over  tracheotomy,  Millard  speaks  of  three  cases  of  croup  fol- 
lowing this  disease  which   were  operated    on   and    recovered. 

Archambault  believed  also  in  the  favorable  influence  of 
whooping-cough.  I  do  not  oppose  this  opinion.  In  eighteen 
cases  of  diphtheria  following  whooping-cough,  six  recovered, 
and  I  can  cite  three  cases  of  croup  tracheotomized   with   sue- 


SURGICAL  TREATMENT. 


505 


cess  under  the  same  circumstances.  The  cachexicB,  especially 
tuberctdosis,  have  given  me  the  following  results :  In  nineteen 
cases  of  diphtheria  consecutive  to  tuberculosis,  death  did  not 
spare  a  single  case ;  six  have  undergone  tracheotomy. 

Archambault  has  been  less  unfortunate.  He  cured  by  tra- 
cheotomy one  tuberculous  patient  attacked  with  croup,  and 
prolonged  the  life  of  another  for  six  weeks. 

Of  thirty-three  patients  attacked  with  diphtheria  during  the 
course  of  various  cachexiae,  two  survived;  three  were  tracheot- 
omized  and  succumbed. 

Diphtheritic  infection,  quite  advanced,  which  appears,  even 
for  the  most  courageous  a  positive  contra-indication,  has  still 
cures  of  the  most  desperate  cases.  I  have  also  seen  patients 
infected  to  the  highest  degree,  having  enormous  glandular 
swelling,  coryza,  cutaneous  diphtheria,  angina  and  croup,  not- 
withstanding, owe  their  lives  to  tracheotomy.  We  should  not 
therefore,  deny  a  patient  the  benefit  of  this  operation  because 
infection  prevails  in  his  case  ;  from  the  time  that  asphyxia  by 
the  larynx  is  manifest,  we  simplify  the  therapeutic  problem 
by  removing  the  asphyxia  ;  and  we  enable  the  organism  to 
react  against  the  infection. 

Conclusions :  Among  the  conditions  which  exercise  over 
tracheotomy  the  most  disastrous  influence,  there  is  not  one 
that  can  be  regarded  as  a  positive  prohibition.  All  have  had 
recoveries.  ' 

The  only  contra-indication  is  the  absence  of  laryngeal  as- 
phyxia. If  we  can  establish  the  fact,  by  the  way,  not  an  easy 
matter,  that  asphyxia  has  not  its  origin  in  the  occlusion  of  the 
larynx,  but  in  the  obliteration  of  the  bronchi,  tracheotomy  can 
be  of  no  benefit ;  it  replaces  the  larynx,  but  is  unable  to  supply 
bronchial  tubes.  Obstacles  located  in  the  trachea  also  justify 
tracheotomy ;  they  are  ordinarily  promptly  expelled  by  the  ar- 
tificial opening.  But  whenever  one  finds  himself  in  the  pres- 
ence of  an  asphyxia  arising  from  stenosis  of  the  larynx, 
whatever  may  be  the  complications  which  darken  the  progno- 
sis, he  is  under  obligation  to  the  patient  to  supply  the  air  of 
which  the  latter  stands  in  need.     Tracheotomy  does  not    pre- 


$06  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

* 

tend  to  cure  croup  ;  it  removes  the  asphyxia,  and  destroys  one 
of  the  most  important  elements  of  the  morbid  complex,  and 
permits  the  economy  and  the  therapeutics  to  combat  the 
others.  By  acting  thus  we  are  exposed  to  numerous  failures 
and  obtain  statistics  not  very  flattering;  but  what  value  can 
this  consideration  have  when  we  are  enabled  to  restore  to 
life,  however  small  may  be  the  number,  patients  doomed  to 
imminent  death. 

The  action  of  the  pioneers  of  tracheotomy  was  perfectly 
justified  ;  they  desired  to  pave  the  way  for  an  operation  against 
which  numerous  prejudices  were  raised.  They  needed  suc- 
cessful results,  which  they  never  would  have  obtained  by  oper- 
ating too  frequently.  Fully  understanding  that  the  interests 
of  the  small  number  should  yield  to  that  of  the  generality,  they 
chose  the  cases  which  to  them  appeared  favorable.  By  this 
course,  laudably  prudent,  they  succeeded  in  making  tracheot- 
omy acceptable  to  such  a  degree  that  no  one  will  longer  se- 
riously question  its  benefits. 

We  may  not  now  act  thus,  we  should,  on  the  contrary,  offer 
those  advantages  freely,  endeavoring  to  make  the  best  of  the 
situation  though  in  appearance  the  most  desperate. 

Preparation. 

We  are  sometimes  suddenly  called  to  a  patient  that  we  find 
already  suffocating.  There  is  no  time  for  details  in  the  prep- 
arations, and  inspired  by  the  difficulties  of  the  situation,  we  op- 
erate at  once.  These  conditions  are  decidedly  bad  and  may 
be  causes  of  numerous  accidents.  It  is  true  that  the  very 
gravity  of  the  situation  may  aid  the  operator,  and  the  state  of 
relaxation  {irsolutioii)  and  anaesthesia  in  which  the  patient  is 
allows  of  operating  almost  as  upon  the  cadaver.  I  have  sev 
eral  times  found  myself  surrounded  by  similar  circumstances. 
The  case  is  not  rare  at  hospitals ;  children  are  sometimes 
brought  there  in  a  condition  similarly  unfavorable.  Aided  by 
one  person  who  held  the  light,  I  have  been  able  to  operate  on 
these  patients  on  their  bed,  with  the  greatest  facility.  Those 
are   exceptional  cases.      In    ordinary   practice    we    follow  the 


SURGICAL    TREATMENT.  507 

case  and  observe  the  course  of  the  disease,  or  are  informed  in 
proper  time  by  the  attending  physician.  It  cannot  be,  more- 
over, too  strongly  recommended  to  the  latter,  that  he  shall  not 
wait  in  calling  for  the  operator  till  the  case  takes  on  a  threat- 
ening action.  At  this  period  one  can  never  foresee  whether 
the  disease  will  progress  slowly  or  rapidly.  We  are  sometimes 
surprised  by  a  sudden  acceleration  which  disappoints  all  ex- 
pectation, if  it  does  not  render  the  operation  useless.  There 
is  every  advantage  in  bringing  the  operator  as  soon  as  the  di- 
agnosis is  confirmed,  and  uniting  with  him  in  all  proper  meas- 
ures. 

Assistatits. — The  first  thing  to  be  done  is  to  find  assistants. 
The  success  of  tracheotomv  often  depends  upon  the  manner  in 
which  one  is  aided.  All  other  precautions  are  secondary  to 
that.  With  experienced  assistants  we  can  always  overcome 
the  local  difficulties  of  illumination  and  implements.  Three  as- 
sistants are  necessary ;  one  stands  in  front  of  the  operator, 
holds  the  light,  passes  the  instruments,  cleanses  the  wound, 
etc.;  the  second  holds  the  head  of  the  patient;  the  third  holds 
the  hands,  the  pelvis  and  the  inferior  extremities. 

It  is  infinitely  preferable  that  the  assistants  should  be  phy- 
sicians, and,  moreover,  those  who  are  posted  in  tracheotomy. 
But  in  an  extreme  case  it  may  suffice  that  the  principal  as- 
sistant has  these  qualifications.  The  members  of  the  family 
never  fail  to  offer  their  services,  but  they  nearly  always  have 
more  of  good  desire  than  self  control  (qualification).  The 
sympathy,  the  anxiety  and  the  sensation  so  common  in  per- 
sons who  for  the  first  time  witness  a  bloody  operation,  may 
cause  faintness,  the  effect  of  which  might  be  to  seriously  dis- 
turb or  compromise  the  operation.  Friends,  neighbors  and 
servants  may  render  assistance,  but  we  should  be  careful  to 
inquire  of  and  examine  them  to  be  assured  that  they  will  not 
give  way.  Females,  even  the  nurse,  should  be  displaced  or 
put  in  a  secondary  position. 

Instnnncnts. — The  operator  should  have  at  hand  the    follow- 
ing instruments. 

A  bistoury  brightened  and  very  sharp.     For  the  purposes  of 


508  DIPHTHERIA,  CROUP  AND  TRACHEOTOMY. 

tracheotomy,  a  special  bistoury  has  been  made,  with  short 
blade  and  moderately  convex.  I  find  no  advantage  in  it.  On 
the  contrary,  I  have  observed  in  several  cases  its  defects,  and 
much  prefer  the  bistoury  with  very  sharp  point.  In  adults,  or 
in  children  of  three  or  four  years,  any  of  the  bistouries  are 
good  enough,  but  below  that  age  the  trachea  is  very  small  and 
yielding,  and  evades  the  instrument  if  it  is  not  very  pointed. 
In  \h&  post-vio)tein  of  a  young  child  which  died  during  the  op 
eration  without  it  being  possible  to  open  the  trachea,one  could 
recognize  upon  this  very  slender  and  very  soft  organ,  the 
marks  of  the  bistoury  in  real  scratches.  The  operator,  who 
used  a  convex  bistoury  had  struck  the  trachea  several  times, 
but  the  trachea  yielded  and  became  depressed  without  being 
penetrated  !     [Nota  bene.] 

All  authors  recommend  a  blunt-pointed  bistoury.  This  in- 
strument is  of  no  use  where  the  operation  is  regularly  done  ; 
it  is  rather  an  inconvenience  as  I'shall  hereafter  show. 

The  dilator  is  still  one  of  the  instruments  considered  as  in- 
dispensable by  the  majority  of  operators,  especially  by  Trous- 
seau. The  introduction  of  the  canula  into  the  tracheal  wound, 
is,  for  the  time  being,  regarded  as  the  most  difficult  step  of  the 
operation ;  one  should  surround  himself  with  all  the  means 
adapted  to  facilitate  this  manoeuvre.  This  estimate  is  exag- 
gerated in  the  majority  of  cases.  If  in  the  operation  practiced 
as  low  down  as  Trousseau  did  it,  the  introduction  of  the  canula 
may  offer  difficulties  because  of  the  depth  at  which  the  trachea 
lies,  it  is  not  so  when  the  incision  is  made  from  the  inferior 
border  of  the  cricoid.  But  in  either  case,  when  the  operation 
is  well  done,  the  dilator  rather  augments  than  diminishes  the 
difficulties.  My  friend  Dr.  Pouquet,  in  his  excellent  thesis, 
has  treated  this  point  with  ability  and  with  the  authority  which 
a  large  practice  in  tracheotomy  has  given  him.  When  the  in- 
cision in  the  trachea  is  central,  straight  and  sufficiently  long,  it 
very  rarely  happens  that  the  canula  cannot  be  easily  intro- 
duced without  the  aid  of  the  dilator,  especially  when  one  uses 
the  canula  of  Luer  of  which  the  end  is  cut  slanting.  Far  from 
being  useful,  the  dilator  is  often  an  obstacle  on  account  of  the 


SURGICAL    TREATMENT.  509 

space  it  occupies  in  the  trachea,  especially  when  this  is  very 
narrow ;  hence,  several  physicians,  expert  in  the  matter  of 
tracheotomy,  have  long  since  abandoned  its  use.  My  inten- 
tion is  not,  however,  to  entirely  proscribe  this  instrument.  But, 
while  very  simple,  the  direct  introduction  of  the  canula  fright- 
ens beginners  ;  however,  the  dilator  has  its  real  advantages.  If 
a  false  membrane,  still  partially  adherent,  should  present  itself 
at  the  moment  of  opening  the  trachea,  the  dilator,  placed  in 
the  wound,  may  keep  it  open  if  necessary,  while  the  trachea 
forceps  is  being  used  to  search  for  the  false  membrane.  If 
haemorrhage  intervenes,  or  any  cause  whatever  retards  the  in- 
troduction of  the  canula,  the  dilator  supplies  its  place  by  hold- 
ing the  wound  open,  and  permits  the  patient  to  respire,  while 
one  provides  against  new  difficulties;  it  also  renders  good  ser- 
vice during  the  dressing  which  follows.  For  these  reasons  it 
should  be  retained  among  the  useful  instruments.  The  number 
of  dilators  which  have  been  invented  from  time  to  time,  proves 
the  imperfection  of  the  instrument.  We  may  reckon  two  prin- 
cipal kinds :  those  which  are  applied  to  the  inferior  extremity 
of  the  wound,  and  those  which  are  placed  at  the  superior  ex- 
tremity. The  first  dilators  invented,  especially  the  one  by 
Trousseau,  belonged  in  the  former  list;  of  all  those  the  best 
is  that  of  Luer.  These  instruments  have  a  fault  common  to 
them  all,  it  is  that  of  requiring  the  canula  to  pass  between  two  " 
rigid  branches  which  remain  too  near  each  other  when  the  in- 
cision is  too  short,  or  when  the  trachea  is  too  narrow,  and  they 
slip  too  easily  from  the  tracheal  wound  when  this  latter  is  too 
long  or  irregular.  Finally,  the  canula  often  enough  escapes 
between  the  branches  of  the  dilator  and  passes  in  front  of  the 
trachea. 

To  remedy  this  latter  defect  Laborde  has  invented  a  dilator 
with  three  blades.  The  third,  situated  at  the  anterior  part, pre- 
vents the  canula  from  escaping  forwards,  and  serves  to  direct 
it.  This  ingenious  instrument  does  not  appear  to  me  to  ac- 
complish all  that  was  expected.  If  the  trachea  is  large  and 
the  incision  sufficient  it  works  admirably  ;  but  then,  one  never 
experiences  any  difficulty.     If,  on  the  contrary,  the   trachea  is 


5IO  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

narrow,  which  condition  is  the  source  of  the  real  difficulty,  the 
three  branches  of  tlie  instruments  occupy  in  the  opening  a 
space  sufficiently  large  to  prevent  the  canuhi  from  entering. 
The  principal  indications  to  be  fulfilled  by  the  inventors  of  di- 
lators, are  to  have  an  instrument  with  branches  very  thin,  yet 
stiff,  so  as  not  to  encumber  the  wound.  The  dilators  which 
are  applied  to  the  superior  angle  of  the  wound  are  preferable. 
The  canula  is  not  required  to  pass  between  their  branches,  and 
it  enters  more  freely.  On  this  idea  the  one  of  Garnier  is  con- 
structed, the  description  of  which  he  gives  in  his  thesis.  How- 
ever, this  instrument  has  branches  relatively  thick,  and  still  oc- 
cupy considerable  space.  I  have  sought  to  retain  the  advan- 
tages of  this  plan,  and  yet  avoid  its  inconveniences.  With  this 
purpose  I  have  taken  the  tenaculum  of  Langenbeck  and  have 
submitted  it  to  some  modifications.  This  instrument,  intended 
to  hold  the  trachea  during  the  operation,  is  composed  on  the 
principle  of  two  pointed,  curved  hooks,  placed  together,  but 
separable  at  will  and  destined  to  hold  the  trachea  as  Chassaig- 
nac  intended.  By  blunting  the  points  of  both  branches  and  in- 
creasing slightly  the  curve  of  the  extremities  one  has  a  real  di- 
lator, with  thin,  resistant  branches,  which  fixes  itself  firmly  in 
the  superior  angle  of  the  tracheal  wound  and  never  suddenly 
slips  out. 

Ca/mlas. — First  of  all,  by  the  example  of  Sanctorius,  the 
canula  of  the  trochar  which  was  used  to  puncture  the  trachea, 
was  left  in  the  wound.  Later,  Fabricius  ab  Acquapendente 
spoke  of  a  canula  with  2i  fla)igc  (rim  or  plate),  because  of  the 
danger  that  a  simple  canula  offered  of  falling  into  the  trachea. 
In  1730  George  Martin,  an  English  surgeon,  carrying  out  the 
idea  of  one  of  his  friends,  invented  the  double  canula,  such  as 
we  now  employ. 

Van  Swieten  recommended  this  instrument.  B  etonneau 
used,  in  his  early  operations,  a  double  straight  canula,  which 
he  soon  replaced  by  a  simple  curved  one.  For  some  time  this 
latter  instrument  prevailed  in  practice.  Its  numerous  incon- 
veniences were  soon  recognized.  Every  time  that  the  canula 
became  obstructed  it  was  necessary  to  remove  it  entirely  or  to 


SURGICAL    TREATMENT.  5  i  I 

push  back  into  the  trachea  the  obstructing  material,  which  was 
not  without  considerable  fatigue  to  the  child,  nor  even  without 
danger.  These  inconveniences  disappeared  with  the  use  of  the 
double  canulas  which  Trousseau  recommended.  This  inven- 
tion was  suggested  to  him  by  an  officer  of  the  artillery,  Gen. 
B.,  whose  daughter  he  had  operated  on  for  a  chronic  laryngitis, 
about  1842. 

Impressed  with  the  extreme  inconvenience  of  the  single 
canula  this  officer  remarked  to  Barthez  during  a  night  which 
they  both  passed  with  the  child,  how  much  the  after-treatment 
of  the  operation  would  be  simplified  if  the  canula  was  com- 
posed of  two  tubes,  one  inside  of  the  other,  in  such  a  way  that 
the  products  from  the  trachea  or  bronchi  would  pass  by  the 
central  tube  alone  ;  the  latter  becoming  clogged,  it  would  be 
sufficient  to  remove  it  without  deranging  the  entire  instrument, 
and  to  replace  it  after  being  cleaned.  On  the  next  day  this 
idea  was  submitted  to  Trousseau  who  accepted  it  with  thanks, 
and  immediately  had  a  double  canula  constructed.  A  quarter 
of  a  circle  was  the  curve  first  adopted  ;  it  was  necessary  to  al- 
low one  of  the  tubes  to  slip  into  the  other  without  effort.  But 
the  result  was  that  the  lower  end  made  a  certain  projection 
forwards,  rubbing,  compressing  and  often  ulcerating  the  an- 
terior part  of  the  trachea. 

The  movable  canula  constructed  by  Luer,  has  removed  these 
imperfections,  as  well  by  the  mobility  of  the  two  pieces  of  the 
canula,  one  upon  the  other,  as  by  diminishing  the  curve  of  the 
tube.  Moreover,  by  the  advice  of  Barthez  the  inferior  extrem- 
ity has  been  beveled  off  (cut  slanting)  at  the  expense  of  the 
anterior  aspect ;  the  instrument  is  thus  much  more  easy  of  in- 
troduction, and  is  better  borne  by  the  trachea.  It  is  really  the 
best  tracheotomy  canula  that  we  possess.  I  should  also  mention 
the  canula  of  Bourdillat.  In  this  instrument  the  outer  tube, 
instead  of  being  cylindrical,  is  formed  of  two  valves  which  are 
introduced  into  the  trachea  upon  an  obturator,  just  as  the 
speculum  of  Ricord.  The  canula  being  in  place,  the  obturator 
is  replaced  by  an  inner  cylindrical  canula  which  separates  the 
two  valves  [Fuller's  bivalve].     Formed  for  the  purpose  of  facil- 


512  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

itating  the  entrance  of  the  canula  into  the  trachea,  this  instru- 
ment has  serious  defects.  Being  presented  at  the  wound 
closed  it  is  impermeable  to  the  air.  It  does  not  permit  the  pro- 
duction of  the  characteristic  whistling  sound  which  indicates 
the  presence  of  the  tube  in  the  air-passage.  Efforts  at  intro- 
duction are  prolonged,  and  false  routes  are  more  com.mon.  It 
does  not,  therefore,  facilitate  the  introduction  of  the  canula. 
As  a  compensation,  it  is  very  useful  as  a  dilating  body.  I  have 
shown  the  use  that  can  be  made  of  it  ^  in  cases  wherein  the 
wound  contracts  rapidly  and  refuses  to  admit  an  ordinary 
canula.  [See  description  of  canulas  in  Stirgical  Anatomy,  p. 32.3 

We  should  always  employ  a  canula  as  large  as  possible,  in 
order  that  the  respiration,  and  consequently  the  h^matosis, 
may  be  freely  performed.  As  rational  as  this  course  may  be, 
we  must  acknowledge  that  it  is  not  always  followed,  and  that 
the  fear  of  difficulty  in  the  introduction  of  the  canula  leads  to 
the  choice  of  one  too  narrow.  We  should  oppose  this  tendency 
and  understand  fully  that  everything  depends  upon  the  man- 
ner in  which  the  incision  is  made.  When  this  is  of  proper  di- 
mensions and  direction  the  canula  gives  no  trouble  in  entering. 
The  precaution  to  assure  one's  self,  before  the  operation,  of  the 
firmness  of  the  canula  to  be  used,  might  be  regarded  as  unnec- 
essary. Several  cases  are  cited,  however,  of  the  dropping  of 
the  canula  into  the  bronchi ;  the  last  one  reported  belonged  to 
Legros,  of  Brussels. 

Some  physicians,  Maslieurat  Lagemard,  Miquel,  of  Amboise, 
and  Tenderini,  according  to  Fiorini,  proscribe  the  canula  ;  they 
keep  the  trachea  open  either  by  means  of  a  special  separator 
— trachea  stretcher — or  by  metallic  hooks  held  by  ribbons,  or 
by  the  aid  of  threads  passed  through  the  edges  of  the  wound. 
This  hazardous  practice  has  never  prevailed. 

[The  late  Prof.  Brainard,  of  Chicago,  and  Dr.  Henry  A.  Martin,  of  Boston, 
strongly  recommended  dispensing  with  tubes ;  also  Roser,  Chevalier,  Dieffenbach, 
J.  Pancoast,  Hodge,Levis,DeF(>rrest  Willard,  Himes,Wm.Pancoast  and  (I.li.  Smith. 

Substitutes  for  tubes  have  been  proposed  by  Marshall  Hall,  Watson,  ofNew  York, 
Bigelow,  Bird,  of  Birkenhead,  Linhart  and  Packard. 

'E'trude  Sur  le  croup  apres  la  tracheotomy,  p.  97. 


SURGICAL  TREATMENT. 


513 


Dr.  John  H.  Packard  in  a  report  to  the  Pennsylvania  State  Medical  Society,  1S85, 
"Suggestions  as  to  substitutes  for  the  tracheotomy  tube,"  gives  the  following  illus- 
trations : 


FUj.3 


Fig.  I  represents  an  apparatus  made  out  of  bent  wire  which  was  found  to  be  intro- 
duced in  the  cadaver  wtih  great  ease,  and  to  hold  its  place  very  firmly.  As  tried,  it 
was  not  rigid  enough  and  needed  some  arrangement  to  enable  the  surgeon  to  set  it, 
and  possibly  in  the  living  subject  there  might  be  some  little  difliculty  in  the  introduc- 
tion. 

Fig.  2  represents  an  instrument  for  lateral  dilatation  of  the  tracheal  wound.  It  is 
very  easy  of  introduction,  and  being  fixed  at  the  proper  degree  of  expansion  by 
means  of  the  bar,  a,  and  the  screw,  b,  may  be  kept  in  place  by  a  strip  of  adhesive 
plaster,  or  by  an  elastic  band  fastened  around  the  patient's  neck. 

Fig.  3  represents  the  model  by  Dr.  Ilopkinsof  an  instrument  with  separable  blades. 
The  lower  one  being  inserted  first,  and  then  the  upper  one,  the  two  are  fastened  to- 
gether by  means  of  the  screw.  This  appliance  would  hold  its  place  in  the  trachea 
without  any  strap  or  confining  band  around  the  neck.] 

The  canula  selected  should  be  supplied  with  a  piece  of  tape 
in  each  eyelet,  intended  to  be  tied  around  the  neck. 

A  piece  of  oiled  silk  or  thin  rubber  cloth  with  a  slit  near 
the  upper  edge  should  surround  the  canula.  It  is  intended  to 
protect  the  skin  from  contact  with  the  plate,  and  from  the  pro- 
ducts which  escape  from  the  tube. 

A  piece  of  tarlatan  of  which  to  make  some  cravats,  and  a 
piece  of  flannel  for  the  same  purpose,  are  equally  necessary. 
These  two  accessories,  so  simple  in  appearance,  are  most  for- 


514  DIPHTHERIA.    CROUP    AND    TRACHEOTOMY. 

tunate  improvements  added  to  tracheotomy.  It  is  from  their 
adoption  by  Trousseau  that  we  date  the  restoration  of  the  op- 
eration. The  air  entering  directly  by  the  wound  without 
being  either  warmed  or  moistened  in  the  nasal  fossae,  increases 
remarkably  the  tendency  to  broncho-pneumonia  so  natural  to 
croup.  The  cravat  remedies  this  unfavorable  disposition.  The 
tarlatan  holds  the  moisture  of  the  expired  air,  and  the  wool 
preserves  the  heat.  The  air  enters  the  canula  only  after  having 
passed  through  a  strainer  where  it  encounters  heat  and  moist- 
ure ;  the  respiration  is  thus  brought  nearly  to  a  physiological 
condition.  The  tarlatan  should  not  be  too  fine;  it  would  then 
have  the  disadvantage  of  muslin  which,  when  wet,  adheres  to 
the  mouth  of  the  tube  and  prevents  the  circulation  of  the  air. 
It  should  be  stiff.  One  should  be  careful  to  rub  it  in  the  hands 
before  applying  it;  its  contact  with  the  skin  of  the  neck  will 
then  be  less  irritating.  The  piece  of  flannel  may  be  substituted 
by  a  simple  linen  handkerchief. 

When  one  practices  the  operation  by  the  process  of  Trous- 
seau, he  must  have  some  blunt  hooks  which  may  serve  to  sep- 
arate the  tissues  and  to  hold  the  vessels  out  of  the  way  of  the 
bistoury.  They  may  be  useful  in  the  combined  procedure 
which  I  employ. 

A  forceps  for  false  membranes,  of  the  model  of  Luer,  should 
be  added  to  the  other  instruments.  An  inflating  tube,  such  as 
is  used  to  excite  respiration  in  case  of  asphyxia  in  the  new- 
born infant,  may  render  important  service  when  one  operates 
on  a  patient  in  a  state  of  apparent  death.  The  canula  being 
put  into  place,  inflation  is  practised  by  means  of  this  tube.  In 
this  way  one  avoids  placing  the  lips  upon  the  wound  or  upon 
the  canula. 

[Parker,  of  London,  has  recommended  an  inflating  tube  by  which  dangers  may  be 
avoided,  and  yet  the  other  objects  of  such  an  instrument  fully  effected.] 

Warm  water,  sponges  and  basins  are  placed  at  the  service  of 
the  principal  assistant.  I  do  not  speak  here  of  artery  forceps, 
threads,  etc.  The  wounding  of  arteries  is  so  rare  that  one 
never  has  occasion,  so  to  speak,  to  ligate  any  of  these  vessels. 


SURGICAL    TREATMENT.  515 

As  to  the  ligating  of  veins,  it  is  difficult,  dangerous  and  useless 
so  far  as  the  branches  of  the  thyroid  plexus  are   concerned. 

For  the  case  of  free  haemorrhage  which  does  not  admit  of 
waiting  till  the  opening  of  the  trachea  and  the  introduction  of 
the  canula,  I  have  had  constructed  by  Collin  haemostatic  for- 
ceps reduced  from  those  of  Pean,  but  broader  at  the  ex- 
tremity. 

Operatijig  Table. — The  patient  should  never  be  operated  on 
while  on  his  bed  except  in  extreme  emergency.  It  is  too  low 
or  too  wide,  or  inclosed  by  the  walls,  rendering  the  approach 
to  the  child  difficult.  The  oval  parlor  tables,  rather  low,  or 
the  long  narrow  kitchen  tables  are  a  great  aid,  as  well  as  the 
dining  tables  with  folding  leaves.  The  table  being  chosen  it  is 
covered  with  a  mattress  from  the  child's  bed,  and,  spread  over 
all,  is  a  sheet.  The  patient's  neck  needing  to  be  made  quite 
prominent  in  front,  a  kind  of  bolster  which  one  can  make  him- 
self is  so  placed  as  to  support  it.  For  this  purpose  the 
cushion  should  be  quite  firm.  If  it  yields  under  the 
weight  of  the  head  and  neck,  the  latter  becomes  relaxed  and 
the  trachea  will  be  less  accessible.  One  can  make  it  with 
sheets  not  folded,  which  may  be  rolled  up.  Archambault  ad- 
vised, in  order  to  give  more  resistance,  to  introduce  into  the 
middle  of  the  bundle  a  beer  jug.  I  am  in  the  habit  of  using 
an  ordinary  pillow,  or  one  of  hair  if  possible,  which  I  roll  upon 
itself,  drawing  it  tightly  and  maintaining  the  constriction  by 
tying  it  with  bands  of  cloth  like  a  sausage.  If  the  bands  are 
wanting,  not  to  be  had,  I  have  recourse  to  pocket  handker- 
chiefs which  I  draw  firmly  and  tie  tightly.  Three  will  suffice, 
one  in  the  middle  and  one  at  each  end.  One  obtains  in  this 
way  a  cushion  which  is  perfectly  firm,  and  answers  every  pur- 
pose. When  finished,  the  cushion  is  rolled  in  the  upper  end 
of  the  sheet  which  covers  the  bed.  Upon  this  sheet  is  spread 
another  folded  double,  which  is  intended  to  envelop  the  patient. 
Position  of  the  Patient. — Formerly  the  operation  was  per- 
formed with  the  patient  seated  in  a  chair,  the  head  thrown 
back.  Trousseau  himself,  in  the  beginning  adopted  this  plan. 
He  soon  abandoned  it  on  account  of  its  inconvenience,  and  be- 


5^6  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

cause  it  favored  syncope,  a  complication  which  cannot  be  too 
much  dreaded.  A  fatal  accident  of  this  kind  led  him  to  place 
the  patient  on  the  back.  It  is  necessary,  however,  to  avoid 
holding  the  head  in  forced  extension  ;  the  embarrassment  of 
this  position  to  the  respiration  may  cause  also  serious  conse- 
quences. Foville  reports  a  case  of  almost  sudden  asphyxia  in 
a  female  placed  in  this  position.  The  dorsal  decubitus  with 
moderate  extension  of  the  head,  recommended  by  Ledran,  is 
the  most  favorable  position  for  the  patient  and  the  most  con- 
venient at  the  same  time,  both  for  the  operator  and  his  as- 
sistants. The  sitting  position  is  reserved  exclusively  for 
adults. 

Illtnnination. — When  one  operates  by  day-light  the  table  is 
placed  near  a  window  so  that  the  patient  has  his  feet  towards 
the  light.  In  any  other  way  the  neck  of  the  patient  is  hid  by 
the  shadow  of  the  assistants.  The  table  should  not  be  placed 
at  right  angles  to  the  window,  else  the  shadow  of  the  oper- 
ator's hand  would  fall  upon  the  neck ;  we  place  it  at  a  certain 
angle  so  that  the  light  will  strike  the  hand  which  holds  the  in- 
strument obliquely.  The  assistant  who  has  charge  of  the 
limbs  and  the  trunk  should  remain  stooping  to  avoid  inter- 
cepting the  light.  No  artificial  light  can  take  the  place 
of  day-light.  The  operation  has  certainly  the  advantage 
of  safety  by  being  performed  during  the  day,  especially  when 
one  has  a  lack  of  help.  When  we  are  sure  the  operation  will 
become  necessary,  it  is  better  to  act  a  little  sooner  than  to 
wait  till  night.  All  plans  of  illumination  have  been  recom- 
mended when  it  is  necessary  to  operate  at  night.  Dining-hall 
lamps,  and  lamps  suspended  from  the  ceiling,  expose  the  sur- 
geon and  his  assistants  to  injury  of  the  head.  If,  to  avoid  this 
danger,  one  raises  them  too  high  they  will  not  give  sufficient 
light.  Candles  are  easily  extinguished,  and  drip  upon  the  pa- 
tient ;  lamps  are  heavy  to  carry,  and  the  glass  may  crack,  and 
the  operation  may  be  interrupted  in  the  most  unpleasant  man- 
ner. The  best  of  all  the  means,  as  it  has  always  appeared  to  me, 
is  the  common  wax  taper  of  a  large  size,  such  as  are  used  in 
hospitals.  This  kind  gives  a  sufficient  light  and  does  not  drip ; 
the  assistant,   standing  in  front  ot   the   surgeon,   holds  it  in  his 


SURGICAL    TREATMENT.  517 

hand  and  approaches  as  near  the  wound  as  needed.  A  lighted 
candle  placed  near  by  enables  it  to  be  relighted  in  case  the 
air  escaping  violently  from  the  trachea  should  extinguish  it. 
I  have  never  employed  any  other  plan,  and  have  always  been 
perfectly   satisfied  with  it. 

Everything  being  thus  prepared,  the  patient  is  divested  of 
his  clothing,  even  of  the  shirt,  and  placed  upon  the  bed.  He 
is  placed  upon  his  back,  the  neck  supported  upon  the  bolster, 
and  quite  projecting;  he  is  rolled  in  the  sheet  which  has  been 
prepared  for  that  purpose,  being  careful  to  bring  the  hands  to- 
wards the  pelvis.  The  assistant  charged  with  this  duty  seizes 
with  each  hand,  through  the  sheet,  one  hand  of  the  patient 
and  presses  it  upon  the  pelvis  which  he  is  holding.  Leaning 
over  strongly  and  almost  lying  upon  the  bed,  he  holds  the  in- 
ferior extremities  of  the  patient  by  the  weight  of  his  body. 

The  principal  assistant  stands  opposite  the  operator,  on  the 
left  of  the  patient;  if  it  is  night,  he  holds  the  light.  The  in- 
struments are  placed  within  his  reach  which  he  passes  when 
needed,  as  are  also  the  sponges  for  cleansing  the  wound.  An- 
other assistant  holds  the  head  by  applying  the  hand  on  each 
side  of  the  head  near  the  angle  of  the  inferior  maxilla.  He 
should  be  careful  not  to  reach  beyond  this  for  fear  of  being  in 
the  way  of  the  operator. 

The  surgeon  stands  at  the  right  of  the  patient,  exposes  the 
neck  and  proceeds  to  operate. 

Ancesthetics. — In  England,  in  the  United  States,  and  in  Ger- 
many the  preparation  is  more  simple  ;  the  use  of  an  anaesthetic 
is  general.  Drs.  Howard  Marsh,  West,  Jenner,  Paget,  the 
physicians  of  the  Hospital  foi  Sick  Cliildreti,  Messrs.  Holmes, 
Smith  and  Gee;  Drs.  Buchanan,  .^f  Glasgow;  Parker,  Voss  and 
Jacobi,  of  New  York;  Braidwood,  Kuhn,  Roser,  of  INIarbourg, 
Wilms,  of  Berlin ;  Llewellyn  Thomas  and  many  others  give 
anaesthetics  to  patients  whom  they  are  going  to  operate  on  for 
croup.  With  them  it  is  a  quieting  measure,  as  well  as  a  means 
of  calming  the  spasmodic  element  of  the  asphyxia. 

According  to  these  authors  chloroform  should  be  given  when 
we  operate  in  the  second  period.     Some  even   pretend   that  it 


Sl^  DIPHTHERIA,  CROUP  AND  TRACHEOTOMY. 

does  not  embarrass  respiration  when  asphyxia  is  advanced. 
Others,  on  the  contrary,  declare  that  they  have  seen  its  use 
considerably  increase  the  symptoms  of  asphyxia. 

We  can  conceive  of  the  use  of  anaesthetics  when  really  nec- 
essary in  operations  during  the  second  period ;  the  child  is 
still  disposed  to  resist,  and  sensation  is  intact;  but  we  must 
stop  the  inhalations  immediately  after  the  incision  through  the 
integuments  is  completed — the  only  painful  step  in  the  opera- 
tion. After  that  they  are  perfectly  useless,  the  asphyx.ia  being 
sufficient  to  anaesthetize  the  patient,  and  to  put  him  in  a  state 
of  relaxation.  Moreover,  it  is  not  proved  that  the  use  of  these 
agents  is  as  innocent  as  some  would  assert.  We  know  there 
is  danger  of  death  by  syncope  in  diphtheria ;  and  anaesthetics 
are  among  the  well-known  causes  of  that  condition. 

[My  experience  with  anesthetics,  especially  with  chloroform,  has  been  such  as  to 
make  me  extremely  cautious  in  recommending  their  use  in  this  operation  for  this  dis- 
ease. 

In  one  case  the  patient  came  near  being  lost,  chloroform  being  the  anaesthetic 
used ;  and  in  another,  though  given  cautiously  and  suspended  entirely  at  the  begin- 
ning of  the  operation,  I  am  inclined  to  think  it  had  much  to  do  in  determining  the 
fatal  result.  For  years  I  have  raised  the  note  of  warning  against  the  use  of  chloro- 
form; and  I  now  say  that,  generally  speaking,  under  the  conditions  usually  existing 
in  this  operation,  it  is  better  to  dispense  with  the  anaesthetic  entirely.] 

The  action  of  these  substances  upon  the  blood,  insufficiently 
oxygenated,  is  of  very  doubtful  innocence.  Besides,  the  res- 
piratory mucous  membrane  when  anaesthetized  does  not  react 
sufficiently  to  expel  the  blood  which  is  introduced  into  the 
trachea  during  the  operation,  nor  to  produce  those  violent 
paroxysms  of  coughing  which,  at  the  moment  of  opening  the 
trachea,  often  favor  the  expulsion  of  false  membranes. 

In  France  this  practice  is  not  common.  We  rarely  operate 
in  the  second  period,  but  at  the  commencement  of  the  third, 
when  resistance  and  sensation  are  often  diminished.  Besides, 
the  little  incision  in  the  skin  is  never  a  cause  of  so  severe  pain 
as  to  demand  the  use  of  means  which  are  not  always  without 
danger[!]. 

The  following  are  the  directions  to  be  followed  in  the  meth- 
ods which  present  themselves  to  the  operator: 


surgical  treatment.  5i9 

Operation. 

Without  speaking  of  the  primitive  processes,  inconvenient, 
insufficient,  dangerous  and  for  these  reasons  fallen  into  desue- 
tude, three  principal  methods  share  the  favor  of  operators. 

The  first,  that  which  Trousseau  recommends,  reaches  the 
trachea  below  the  thyroid  body,  often  in  the  space  comprised 
between  the  third  and  the  seventh  rings,  as  advised  by  Vel- 
peau.  This  is  tracheotomy  properly  so  called.  I  shall  call  it 
low  tracheotomy. 

The  second  opens  the  trachea  in  its  superior  part,  starting 
from  the  inferior  border  of  the  cricoid  cartilage,  that  is,  through 
the  upper  two  or  three  rings.  I  shall  designate  it  under  the 
name  of  high  ti'acJieotoviy. 

The  third,  indicated  by  Boyer,  concerns  the  cricoid  and  the 
first  two  rings ;  that  is  crico-tracheotoniy ,  (laryngo-tracheot- 
omy).  The  place  of  election  is  not  the  only  point  that  has  oc- 
cupied the  attention  of  practitioners.  Some  have  found  ad- 
vantage in  operating  rapidly,  others  have  advised  deliberation. 
This  question  has  been  much  discussed.  The  slow  operation, 
so  valliantly  supported  by  Trousseau  and  Millard,  still  claims 
numerous  partisans ;  the  rapid  operation,  on  its  part,  has  made 
important  conquests. 

The  operator,  then,  finds  himself  in  the  presence  of  several 
methods  which  difier  respecting  the  region,  and  in  reference  to 
the  slowness  or  the  rapidity  with  which  they  should  be  com- 
pleted. The  problem  is  less  complicated  than  might  appear. 
The  method  of  Trousseau  should  be  performed  slowly  for  fear 
of  accident.  High  tracheotomy  may  also  be  performed  slowly 
and  also  crico-tracheotomy,  but  both  these  have  the  great  ad- 
vantage of  allowing  promptness  in  their  execution.  When  it 
is  necessary  to  operate  on  a  patient  in  an  advanced  state  of 
asphyxia,  it  is  necessary  to  proceed  rapidly  under  penalty  of 
exposing  the  patient  to  die  during  the  operation. 

Still  other  considerations  enter  into  the  choice  of  method. 
They  will  be  better  understood  after  each  procedure  shall  have 
been  set  forth  in  detail. 


520  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

Inferior  Tracheotomy,     (Low  operation). 

This  comprises,  in  its  execution,  three  principal  steps:  i. 
Division  of  the  soft  parts  down  to  the  trachea;  2.  Incision  of 
the  trachea;   3.   Introduction  of  the  canula. 

Division  of  the  Soft  Parts. — The  operator,  standing  on  the 
right  of  the  patient,  ascertains  the  position  of  the  trachea  ;  that 
is  one  of  the  important  preHminaries  of  the  operation;  it  is  not 
always  easily  accomplished. 

If  the  child  is  very  young,  if  the  neck  is  fat  and  the  trachea 
compressible,  we  find  difficulty.  We  should  seek  for  the  tuber 
cle  of  the  cricoid  cartilage  as  our  guide.  Under  [the  circum- 
stances to  which  I  have  just  referred  we  do  not  always  find  it 
easily :  it  may  be  confounded  with  that  of  the  thyroid,  and  this 
cartilage  be  divided  in  its  entire  length.  The  error  has  been 
committed  several  times  and  should  be  avoided.  Peter  gives 
excehent  advice  for  this  case. 

[In  one  case  I  found  it  verj'  difficult  to  recognize  the  cricoid  with  any  degree  of 
certainty.  It  was  rather  by  recognizing  its  relative  oosiiion  to  other  parts  that  I  de- 
termined at  what  point  to  inti-oduce  the  tenaculum  below  it.] 

The  patient  being  in  the  position  desired  for  the  operation, 
one  should  count  the  prominences  which  appear  on  the  surface 
of  the  neck  below  the  chin  on  the  median  line.  The  first  is 
that  of  the  os  hyoid,  the  second  that  of  the  thyroid  ;  the  third 
and  last,  that  of  the  cricoid.  This  point  being  recognized  it  is 
marked  either  with  the  nail  or  with  ink,  and  an  incision  is  made 
on  the  median  line,  extending  from  this  point  to  within  a  short 
distance  of  the  sternal  depression.  It  is  absolutely  necessary 
that  the  incision  be  central,  in  default  of  which  one  risks  los- 
ing his  course  from  the  start,  passing  to  the  side  of  the  trachea 
and,  cutting  on,  reaches  the  cervical  vertebrae,  and  is  very 
fortunate  if  he  does  not  injure,  in  making  this  track,  some  im- 
portant organ,  a  jugular  vein,  for  example.  To  avoid  this  er- 
ror, one  may,  after  the  example  of  Trousseau,  and  before  com- 
mencing the  operation,  mark  out  the  track  for  the  bistoury  by 
making    a   line    with    ink    or    with    a    cork   blackened    in  the 


SURGICAL  TREATMENT. 


521 


flame  of  a  candle.  The  nail  of  the  left  index  finger  often 
serves  for  the  experienced  operator  to  recognize  the  trachea. 
This  finger  answers  as  princal  guide  during  the  entire  opera- 
tion, and  it  should  frequently  examine  the  position. 

The  integument,  the  subcutaneous  connective  tissue  and  the 
cervical  aponeurosis  are  to  be  successively  divided.     Reaching 
the  median  raphe,  which  separates   the   sterno-hyoid   muscles, 
the  bistoury  is  directed  upon  this  line,  and  the  incision  is   con- 
tinued by  short  strokes,  while  the  left  hand,  armed  with  a  blunt 
hook,  draws  aside  one  of  these  muscles.     The  assistant,  armed 
with  a  similar  hook,    does  the   same   with    the    other    muscle. 
The  sterno-thyroid  muscles  are  to  be  separated   in  the  same 
manner.      During  this  time   the  assistant  attends   to   sponging 
quickly  and  frequently  so  as  to  keep  the  bottom  of  the  wound 
constantly  quite  clean.  In  this  way  we  avoid  the  thyroid  body, 
at  least  when  it  is  not  very  large.     In  the   latter  case,    even  if 
the  incision  is  exactly  in  the  middle,  we  come   down   in   front 
of  the  isthmus  of  this   gland,    ordinarily  quite   a  thin  strip,   so 
.  delicate  that  we   may   very    frequently    cut    it    without    being 
aware  of  it.     We  next  encounter  the   thyroid  venous  plexus, 
and  the  median  thyroid  artery  (thyroidea  ima,    artery   of  Neic- 
batier  and  Erdmann^  the  existence   of  which  is   quite    excep- 
tional.    This  is  really  the  critical  moment  in  the  operation,  for 
these  vessels  are  not  the  only  ones  which   demand   our   careful 
attention.     The  left  internal  jugular  vein,  the   left  common  ca- 
rotid which  sometimes  crosses  the  trachea,  the  left  subclavian 
vein,  and  even  the   brachio-cephalic  trunk,  innominata,  which 
sometimes  rises  considerably  above  the  margin  of  the  sternum, 
may  be  found  under  the  bistoury.     To  wound  them  is  to  ex- 
pose the  patient  to  certain    death ;   they   are    fortunately   very 
rare  cases.     Notwithstanding,  we  must  manipulate   with   great 
circumspection  in  this  dangerous  region ;  each  stroke   of  the 
knife  should  be  preceded  by  a  minute  exploration  with  the  aid 
of  the  finger  and  the  eye.     Every    vein    is    dissected    up    and 
held  aside  by  the  blunt  hook.     Proceeding  thus  we    arrive   at 
the  trachea;  examine    it    with   care;  the  rings   present  to  the 
touch  certain  characteristics  by  which  all  error  may  be  avoided. 


522  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

Without  this  precaution  we  are  liable  to  mistake  for  the  tra- 
chea one  of  the  sterno-thyroid  muscles,  which  in  form  *nd  size 
very  closely  resemble  this  air-passage.  In  consequence  of  this 
en  r  I  have  seen  this  muscle  pierced  with  thrusts  from  the  bis- 
toury. 

2,  Incision  of  the  Trachea. — When  clearly  recognized  the  tra- 
chea is  to  be  exposed  and  punctured.       Trousseau,  without  in- 
dicating exactly  the  point  where  the  cutting  instrument  should 
be  thrust  in,  advises  it  at  some  distance  from  the  larynx.    Vel- 
peau  prefers  to  cut  from  the  fourth   to  the  sixth    ring  ;    Guer- 
sant  recommends  to   make  the  puncture  between    the    fourth 
and  the  fifth.  A  hissing  produced  by  the  rapid  entrance  of  the 
air   indicates  that  the   object  has    been    reached.        Without 
removing  the  knife  from  the  wound  the  incision  is  to  be  pro- 
longed upwards  or  downwards  according  as  the  puncture  has 
been  made  in  the  trachea   in  the   inferior  or   in   the    superior 
part  of  the  wound.      If  the  puncture  has  been  made  at   the   in- 
ferior part,  the  edge   must  be  presented   upwards-     This  latter 
method,  employed  at  one  time  exclusively,   is  generally   aban-, 
doned.     It  has  been,  however,    quite    recently  recommended 
again  by  Mr.    Howse,    of   London.^     The    incision    should  be 
about  a  centimetre  and  a  half  long.     One  should  avoid  having 
recourse  to  the  probe  pointed  bistoury  for  the  purpose    of  en- 
larging the  incision.     It  is  necessary,  as  far   as  possible,    that 
the  puncture  and  incision  be  made  without  removing  the  knife 
from'  the  trachea.     It  is  the  only  method  of  making  a  straight 
tracheal  incision.     But  if  it  is  found  that  the  incision    is  too 
short,  or  if  it  has  been  punctured  by  inadvertance,  which  often 
happens,  and   the   knife    is    withdrawn    from    the    wound,    we 
should  introduce  the  probe-pointed   bistoury   and    remove   the 
constriction  upwards.     This  manipulation  is  not   without  dan- 
ger.    Pouquet  has   showed  its  inconveniences.     If,    following 
the  precept  of  Trousseau,  the  probe-pointed  bistoury  is  carried 
to  the  bottom  of  the  wound,  there  is  often  risk  of  pushing  it  in 
a  different  direction  from  the  first  and  causing  an  irregular  in- 

'Guv's  Hospital  reports,  1875,  P*  495* 


SURGICAL    TREATMENT.  523 

cision.  This  operative  defect  may  be  still  more  serious  if, 
finding  the  incision  too  short  while  the  dilator  is  in  the  wound, 
we  attempt  to  divide  the  tracheal  wall  extended  between  the 
branches  of  the  forceps.  Under  these  conditions  the  normal  di- 
rection ol  the  tissues  is  changed,  and  the  second  line  of  incision 
is  almost  i.ev.i'  an  exact  extension  of  the  first.  Finally  we  ob- 
tain an  irregular  incision  which  dilates  incompletely,  and  some- 
times tears  under  the  efforts  of  the  dilator.  It  is  then  that 
the  canula  encounters  great  difficulties  in  entering  the  trachea 
and  may  be  inserted  in  the  surrounding  sheath  of  connective 
tissue.  By  making  the  puncture  and  incision  at  once  this  dan- 
ger is  avoided. 

3.  Introduction  of  the  Canula. — After  the  trachea  is  opened 
the  tube  must  be  introduced.  The  physician,  taking  the  dilator 
in  the  right  hand,  introduces  it  into  the  wound  by  directing  it 
upon  the  nail  of  the  left  index  finger  which  holds  one  of  the 
margins  of  the  tracheal  wound.  At  this  moment  it  often  hap- 
pens that  false  membranes  present  themselves  at  the  wound, 
'  and  a  violent  effort  at  coughing  sometimes  expels  them,  or  if 
not,  the  physician  siezes  the  tracheotomy  forceps  with  the  left 
hand  and  removes  the  floating  material.  Laying  aside  the  for- 
ceps he  takes  the  canula  in  the  same  hand  and  introduces  it 
by  presenting  the  bevel-edge  in  the  side  of  the  wound,  then, 
tnrning  a  quarter  of  a  circle,  he  makes  it  enter  entirely  into 
the  trachea.  The  dilator  which  is  applied  at  the  upper  part  of 
the  wound  is  now  held  in  the  left  hand,  and  permits  the  ma- 
nipulations of  the  canula  with  the  right  hand. 

It  is  still  better  to  dispense  with  the  dilator.  It  is  no  more 
difficult  than  the  other  method  ;  a  little  courage  and  coolness 
suffice.  The  left  index  introduced  into  the  wound  catches  the 
edge  of  the  tracheal  wound  with  the  finger  nail ;  the  canula, 
guided  upon  the  finger,  enters  with  facility  into  the  trachea. 

Whatever  method  may  be  employed,  it  is  necessary  to  act 
with  gentleness ;  if  resistance  is  met  with,  one  should  stop, 
withdraw  the  tube  a  little,  be  sure  of  the  condition  of  the 
parts,  and  recommence  in  the  same  manner.  The  employment 
of  force  leads  only  to  making  false  routes;  the  canula   imbeds 


5^4  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

itself  by  the  side  of  the  trachea  surrounded  by  connective  tis- 
sue. One  supposes  the  instrument  in  place  and  yet  the  as- 
phyxia continues.  He  is  quickly  informed  of  this  error  by  the 
aggravation  of  the  patient's  condition  and  by  the  cessation  of 
the  whistling  which  indicates  the  passage  of  air  by  the  tube. 
In  such  a  case  he  hastens  to  remove  the  canula  and  to  com- 
mence again  with  more  care. 

In  fact  this  part  of  the  operation  requires  the  same  dexterity 
as  catheterism  of  the  urethra.  The  false  passages  which  oc- 
cur in  both  cases  from  the  inexperience  of  the  operator  are 
equally  fatal.  I  need  not  say  what  occurs  in  the  case  of  a 
urethral  false  passage  ;  the  tracheal  false  passage,  even  when 
it  does  not  provoke  immediate  asphyxia,  is  the  cause  of  sepa- 
rations (detachments)  along  the  sides,  and  especially  along  the 
front  part  of  the  trachea.  These  separations  are  the  starting 
points  of  abscesses  of  the  neck,  and  sometimes  of  abscess  of 
the  mediastinum,  which  seriously  compromise  the  success  of 
the  operation.  While  having  a  perfect  steadiness  of  hand,  the 
physician  should  manifest  an  unchangeable  coolness  during 
this  part  of  tracheotomy.  This  is  in  fact  an  exciting  moment; 
the  patient  is  struggling,  the  air  comes  rushing  from  the  tra- 
chea bringing  a  shower  of  blood,  mucus  and  debris  of  false 
membranes  which  fall  upon  the  operator,  soiling  his  face,  not 
excepting  his  eyes,  nose  or  mouth.  This  scene  is  well  calcu- 
lated to  frighten  beginners  ;  quite  frequently  it  produces  these 
unpleasant  results  greatly  to  the  injury  of  the  patient.  It  is 
necessary,  therefore,  to  be  forewarned  and  to  remain  undis- 
turbed. 

The  canula  being  in  place,  the  patient  should  be  raised  at 
once  and  seated  upon  the  table,  and  the  strings  of  the  canula 
tied.  The  constriction  should  not  be  too  tight,  but  should  be 
sufficient  to  bring  the  canula  well  down  and  not  permit  it  to 
escape  from  the  trachea.  One  should  see  that  the  knot  is  suf- 
ficiently tight  that  it  may  not  afterward  become  loose.  The 
details,  which  appear  perhaps  too  minute,  have  impressed 
themselves  upon  me  by  accidents  resulting  in  death,  of  which 
I  have  been  a  witness. 


SURGICAL    TREATMENT.  525 

A  cravat  of  tarlatan  is  put  around  the  neck,  and  then  a  sec- 
ond of  woolen.  The  patient  is  then  washed  with  tepid  water, 
cleansed  of  blood  spots  and  returned  to  his  bed  where  there 
is  awaiting  him  a  well  warmed  sheet  in  which  he  is  to  be 
wrapped,  and  dressed  after  the  first  sleep  which  usually  follows 
the  operation.  To  finish  up  he  is  to  have  a  little  sweetened 
wine  to  drink. 

Practiced  according  to  this  process,  tracheotomy  is  what 
may  be  called  a  difficult  operation.  It  requires  of  the  surgeon 
extreme  circumspection  because  of  the  nature  of  the  region  in 
which  he  operates.  This  vicinity  is  not  without  danger  ;  the 
risks  of  haemorrhage  present  themselves  at  every  step,  and  the 
ability  of  the  operator  and  the  slowness  of  the  operation  do 
not  always  insure  ag^ainst  them.  We  know  from  Guerin  that 
the  left  internal  jugular  has  been  wounded  on  several  occa- 
sions. [!]  Bichat  cites  a  case  of  section  of  the  left  primitive 
carotid,  and  Axenfeld  reports  a  case  in  which  the  innominate 
artery  was  injured.  Pouquet  found,  in  an  autopsy,  this  artery 
in  connection  with  the  inferior  angle  of  the  tracheal  incision  ; 
the  operation  was  made  a  little  low  because  of  the  abnormal 
development  of  the  isthmus  of  the  thyroid.  Afiditional  diffi- 
culties of  another  kind  are  encountered  still  in  this  region. 
The  older  the  child  is,  the  larger  is  the  trachea  and  the  more 
easily  recognized,  but  in  a  little  child  it  is  otherwise.  The  tube 
is  narrow  and  its  walls  are  thin  and  soft.  However  slightly 
fat  the  neck  may  be  the  trachea  is  movable,  retreats  before  the 
finger  that  is  seeking  it,  and  moves  to  the  left.  The  operation 
is  then  extremely  difficult,  the  search  is  tedious,  the  surgeon, 
if  he  is  not  very  expert,  becoming  embarrassed  by  the  bleed- 
ing and  by  the  increasing  asphyxia,  and  losing  his  guide, 
punctures  the  sterno-thyroid  muscle,  and  continuing  to  cut, 
goes  down  to  the  vertebral.  This  is  the  principal  cause  of 
death  during  the  operation  without  reckoning  the  haemor- 
rhage which  does  not  fail  to  add  its  share. 

I  have  often  met  with  an  anatomical  peculiarity  which 
places  the  operator  in  the  same  embarrassment.  The  trachea 
deviates  towards  the  left,  and  the   median    incision    does    not 


526  DIPHTHERIA,  CROUP  AND  TRACHEOTOMV. 

strike  it,  the  knife  punctures  it  in  the  right  half  or  leaves  it  to 
the  side.  The  same  thing  occurs  as  in  the  case  above,  only  in 
that  the  deviation  is  artificial  and  produced  by  pressure  of  the 
finger;  in  the  latter  case  it  is  natural.  To  overcome  these 
difficulties  one  has  advised,  after  the  cutaneous  incision,  to  use 
almost  entirely  the  grooved  director  to  separate  the  tissues 
and  hold  them  aside.  This  modus  facioidi  is  advantageous  so 
far  only  as  the  separation  of  the  muscles  and  diverting  the 
vessels  is  concerned.  But  if  one  wishes  to  divide  the  apon- 
euroses of  the  neck  which  are  sufficiently  resistant,  he  must 
employ  considerable  force,  and  risks  making  a  mistake  and 
producing  extensive  detachments  which  at  a  later  period  pro- 
duce abscesses,  more  or  less  extensive,  and  deep  gangrene  of 
this  region.  It  is  better  when  one  encounters  an  aponeurosis 
to  slip  the  director  under  it  and  divide  the  membrane  upon  it, 
and  then  continue  the  manipulations  with  the  director.  These 
remarks  show  that  seeking  for  the  trachea  is  the  most  difficult 
step  of  tracheotomy,  and  more  trjang  than  the  introduction  of 
the  canula,  as  has  been  stated.  The  patients  which  succumb 
during  the  operation  nearly  all  die  from  asphyxia,  in  conse- 
quence of  the  delay  in  opening  the  trachea.  When  this  is  once 
opened  the  introduction  of  the  dilator  permits  the  entrance  of 
the  air  and  allows  the  patient  to  breathe  ;  and,  in  the  absence 
of  haemorrhage,  nothing  is  lost,  and  in  proportion  as  the  in- 
cision is  well  made  so  will  the  canula  enter  with  facility. 

The  operation  performed  below  the  thyroid  body  offers, 
therefore,  serious  dangers,  due  to  the  vicinity  of  large  vessels 
and  to  the  depth  and  the  mobility  of  the  trachea.  And  how- 
ever experienced  the  surgeon  may  be,  he  may  not  flatter  him- 
self that  he  can  always  avert  them.  [See  Dr.  Winters'  report. 
Med,  Record.  Dec.  13,  1884;  and  p.  481. 

High  Tracheotomy. 

The  dangers  of  tracheotomy,  properly  speaking,  have  im- 
pressed all  observers.  Attempts  have  been  made  to  remove 
these  dangers,  and  with   this   object  in   view   the   incision  has 


SURGICAL     TREATMENT.  52/ 

been  practised  at  the  expense  of  the  upper  rings  of  the  tra- 
chea. 

The  objections  which  have  been  offered  against  this  method 
of  operating  are  purely  theoretical.  The  only  one  which  has 
been  put  into  form  is  the  inconvenience  to  the  vocal  cords  from 
the  prolonged  retention  of  the  canula  in  their  vicinity.  The 
objection  is  valid  when  the  cricoid  is  divided,  but  when  the  in- 
cision is  commenced  below  this  cartilage  I  find  it  no  longer 
well  founded. 

The  presence  of  the  isthmus  of  the  thyroid  body  may  furnish 
an  argument  against  this  operation.  But  in  the  immense  ma- 
jority of  cases  this  portion  of  the  gland  is  only  a  very  thin  strip 
which  passes  unnoticed.  When,  by  chance,  it  is  large,  it 
bleeds  it  is  true,  but  it  is  a  haemorrhage  which  the  press- 
ure of  the  finger  or  the  blunt  hook  easily  arrests.  It  is  never 
comparable  to  that  furnished  by  the  thyroid  vessels. 

These  slight  inconveniences  are  counterbalanced  by  impor- 
tant advantages.  The  veins  are  few  and  slightly  developed, and 
one  is  certain  not  to  wound  either  the  jugular  vein  or  the  left 
common  carotid,  the  innominate,  nor  the  subclavian  vein.  The 
introduction  of  the  canula  is  easier,  the  detachments  are  less 
frequent,  and  emphysema  is  more  rare.  Hence,  all  contribute 
to  give  preference  to  this  operative  procedure.  In  it  there  are 
two  principal  methods  :  the  slow  or  deliberate,  and  the  quick 
or  rapid. 

The  Slow  Operation. 

I  have  nothing  special  to  say  upon  the  manner  of  operating 
under  these  circumstances.  The  course  to  follow  is  exactly 
the  same  as  in  tracheotomy,  properly  so  called.  The  incision  in 
the  integument  should  be  made  higher;  it  commences  from 
the  superior  border  of  the  cricoid  cartilage  and  extends  about 
4  centimetres  (i^/^  in.).  The  subjacent  tissues  are  to  be  di- 
vided and  separated  with  the  same  care,  the  vessels  held  aside 
with  the  same  precautions,  which  from  their  small  number  give 
little  trouble.     Finally,  the   trachea   being  exposed,    {denudce) 


528  DIPHTHERIA,    CKOUP    AND    TRACHEOTOMY. 

is  to  be  punctured  immediately  below  the  tubercle  of  the  cri- 
coid, the  bistoury  having  the  edge  directed  downwards  and 
being  guided  by  the  nail  of  the  left  index  which  rests  upon  this 
tubercle.  The  puncture  is  immediately  followed  by  the  in- 
cision to  the  extent  of  about  0.015  (Ysin.);  then  the  canula  is 
to  be  introduced  either  with  or  without  the  dilator,  following 
the  rules  given  for  the  preceding  operation. 

The  Rapid  Operation'. 

The  model  of  the  rapid  operation  is  the  process  of  Chas- 
saignac.  This  surgeon  found  first  the  tubercle  on  the  cricoid, 
then  held  it  by  pressing  it  a  little  upwards  by  means  of  the  nail 
of  the  left  index  finger.  Now  taking  in  the  right  hand,  as  one 
would  hold  a  carving  knife,  a  tenaculum  with  a  groove  on  the 
back,  he  places  this  instrument  at  right  angles  to  the  trachea 
and  punctures  this  tube.  He  then  gives  to  the  handle  of  the 
tenaculum  a  circular  movement  which  brings  it  upwards  and 
parallel  to  the  trachea.  When  once  in  this  position  the  handle 
is  to  be  seized  by  the  left  hand  and  drawn  strongly  upwards. 
The  right  hand  armed  with  a  bistoury,  introduces  the  point  of 
this  instrument  into  the  groove  of  the  tenaculum,  and  thence, 
without  hesitation,  by  one  stroke  into  the  trachea  at  the  point 
where  the  tenaculum  is  implanted.  The  operation  is  com- 
pleted by  cutting  at  the  same  time  the  skin  and  three  or  four 
rings  of  the  trachea.  The  canula  is  finally  introduced  by  aid 
of  the  dilator. 

This  process  is  very  brilliant,  but  it  succeeds  especially  in  the 
easy  cases,  where  it  is  of  little  use  ;  it  exposes  to  unforeseen 
accidents  in  the  difficult  cases  in  which  it  would  be  especially 
applicable.  In  the  easy  operations,  that  is  to  say,  when  the 
neck  is  moderately  fat,  when  the  trachea  and  larynx  make  a 
strong  projection,  it  is  easy  to  find  the  cricoid  tubercle  and  to 
insert  the  tenaculum  there.  But  when  the  neck  is  fat,  when 
the  larynx  and  trachea  are  deep  and  movable,  it  is  difficult  to 
recognize  the  tubercle  and  still  more  difficult  to  catch  it.  After 
numerous  experiments  made  upon  the  cadaver  I  am  convinced 


SURGICAL  TREATMENT.  529 

that  it  is  not  always  easy  to  catch  the  tubercle  by  means  of  the 
tenaculum  through  the  skin,  even  by  making  previously  a 
slight  incision  in  the  integument.  Several  observers  have  wit- 
nessed this  fact.  Some  operators  have  seen  the  bistoury, 
when  conducted  by  the  tenaculum  hooked  in  some  other  part 
than  the  trachea,  carried  astray  in  a  most  unfortunate  manner. 
Analogous  observations  have  been  made  abroad.  Dr.  Marsh 
reports  three  cases  of  the  operation  made  according  to  this 
process  in  which  the  canula  was  placed  by  the  side  of  the 
trachea. 

In  another  case  of  the  same  kind,  cited  by  Dr.  Thomas 
Green,  the  trachea  was  untouched  and  the  canula  lay  on  the 
outside  of  it. 

This  mode  of  operating,  therefore,  does  not  always  meet  the 
very  important  indication  of  holding  the  trachea  in  the  cases  in 
which  it  is  deep  and  movable.  Other  objections  have  been  of- 
fered to  it.  Sometimes  it  subjects  the  trachea  to  a  twisting 
movement,  which  requires  that  the  incision  be  not  made  on 
the    median  line. 

In  children  in  which  the  trachea  is  very  narrow  one  runs  the 
risk  of  transfixing  this  tube  and  incising  the  oesophagus.  Peter 
has  witnessed  such  an  accident  in  an  operation  performed  ac- 
cording to  this  process.  The  canula  was  introduced  into  the 
oesophagus,  and  the  patient  died  at  once  asphyxiated.  It  has 
been  strongly  accused  of  hastening  asphyxia  by  immobilizing 
the  trachea.  This  objection,  it  seems  to  me,  is  based  rather 
upon  theory  than  practice.  The  time  during  which  the  trachea 
is  held  is  very  brief,  and  it  is  difficult  to  admit  that  it  can  really 
hasten  asphyxia.  It  has  also  been  charged,  without  much  evi- 
dence, with  favoring  hsemorrhage  by  division  of  the  thyroid 
body.  Generally  speaking,  it  exposes  but  little  to  haemor- 
rhage ;  the  vessels  are  few  in  this  region,  and  the  elevation 
given  to  the  trachea  causes  those  which  might  be  found  in 
front  to  slip  to  the  sides.  As  to  the  section  of  the  thyroid 
body  it  is  trifling  if  the  incision  is  exactly  in  the  middle.  More- 
over, the  best  means  for  arresting  haemorrhage  being  the  in- 
troduction of  the  canula,  as  we  shall  see  hereafter,  this  method 


530  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

of  operating  has  nothing  to  envy  (desire)  of  the   others  in  this 
respect. 

The  process  of  Chassaignac  gave  rise  to  that  of  Langenbeck. 
The  tenaculum  is  composed  of  two  hooks  in  juxta-position, 
separated  by  a  groove  as  far  as  the  point.  At  this  point  they 
are  apphed  accurately  one  against  the  other  in  such  a  manner 
as  to  make  a  single  point.  The  Berlin  surgeon  does  not  apply 
his  instrument  to  the  trachea  only  after  the  latter  has  been  ex- 
posed by  the  ordinary  method.  He  then  inserts  it  between 
two  rings,  holds  the  trachea,  separates  slowly  the  two  hooks 
by  means  of  a  screw  and  makes  the  puncture  of  the  trachea  be- 
tween the  two,  and  then  the  incision  as  in  the  process  of  Chas- 
saignac. The  two  branches  which  remain  fixed,  one  in  each 
side  of  the  incision,  are  separated  by  the  action  of  a  spring 
{pedal);  each  one  holds  a  lip  of  the  wound;  this  is  dilated  and 
the  canula  is  introduced.  Hence,  this  instrument  serves  at 
once  the  purpose  of  a  tenaculum  and  a  dilator.  Its  application 
is  far  from  being  simple  ;  it  is  not  easy  to  catch  with  the  hook 
the  trachea  at  the  bottom  of  a  wound  somewhat  deep,  nar- 
row and  full  of  blood,  while  the  patient  is  struggling  and  con- 
tracting the  muscles  of  the  neck,  the  trachea  often  small  and 
slippery  with  blood.  It  is  a  quite  useless  complication  of  the 
operation.  If  the  fixing  of  the  trachea  before  the  incision  of 
the  integuments  is  a  logical  and  accessible  thing,  it  is  very 
difficult  and  without  object,  after  this  step,  in  tracheotomy. 
At  this  time  the  tube  is  under  control,  and  it  can  be  punctured 
easily,  and  the  operation  terminated  by  the  ordinary  method 
with  much  less  difficulty. 

Isambert  comprehended  the  defects  of  this  mode  of  oper- 
ating;  he  gave  to  the  instrument  a  larger  curve,  and  at  the 
same  time  it  was  made  stronger  and  sharper.  Thus  modified  the 
instrument  is  inserted  into  the  trachea  through  the  integument, 
the  same  as  with  Chassaignac's  instrument.  The  puncture 
with  the  bistoury  is  made  between  the  slightly  separated 
branches ;  then  the  skin  and  trachea  are  divided  at  a  single 
stroke.  The  action  of  the  pedal  (spring)  subsequently  sepa- 
rates the  margins  of  the  wound,  as   well    those   of  the  trachea 


SURGICAL    TREATMENT.  5  3  I 

as  those  of  the  integument,  and  then  the  canula  is  to  be  intro 
duced. 

The  author  is  very  much  pleased  with  this  improvement.  It 
is,  without  question,  very  ingenious. 

I  do  not  hesitate  to  recognize  with  the  author  that  this  in- 
strument may  present  advantages  in  civil  practice,  and  princi- 
pally in  the  country  where  one  is  compelled  to  operate  with 
an  insufficiency  of  assistance  and  light.  Other  instruments  have 
been  invented  by  Marc  See,  Maisonneuve,  and,  recently,  by 
B.  Anger,  for  performing  tracheotomy  mechanically.  These 
instruments  comprise  the  knife  and  the  dilator.  Like  all  in- 
struments of  this  kind,  they  give  brilliant  results  on  the  cada- 
ver and  upon  the  adult ;  but  acting  as  if  the  relation  of  the 
parts  was  invariable,  their  range  of  application  is  very  limited, 
especially  in  children. 

Bourdillat  has  proposed  another  rapid  process  of  operating. 
Instead  of  operating  at  a  single  step,  like  Chassaignac,  he  fin- 
ishes all  in  two  steps.  The  first  divides  the  integuments  down 
to  the  trachea,  and  the  second  incises  the  trachea.  The  cricoid 
tubercle  being  recognized,  a  line  is  drawn  with  ink  as  a  guide 
to  the  incision.  The  larynx  is  then  held  between  the  fingers 
of  the  left  hand;  the  knife  divides  at  a  single  stroke  all  the  tis- 
sues in  front  of  the  trachea  to  the  extent  of  from  0.015  to  0.02 
(Ys  to  Ys  in-)-  -^^  t^^"  makes  the  puncture  and  the  incision 
into  the  trachea.  The  depth  of  the  first  incision  should  be 
about  O.oi  (75  in.) ;  in  a  child  less  than  two  years  the  depth  is 
less.  As  a  guide  the  author  recommends  that  a  mark  be  made 
on  the  blade  of  the  bistoury  o.oi  (Ys  in.)  from  the  point.  He 
also  advises  to  endeavor  to  enter  the  trachea  at  once  through 
the  integuments.  From  the  fact  that  it  requires  no  special  in- 
strument, this  process  should  be  preferred  to  the  preceding 
ones.  But  how  can  one  be  certain  to  cut  at  one  stroke  all  the 
tissues  lying  in  front  of  the  trachea  ?  The  guide  or  land-mark 
on  the  blade  of  the  knife  often  leads  to  error;  one  risks  punc- 
turing the  trachea  without  desiring  it,  or  missing  it  a  certain 
distance.  In  the  first  case,  the  tracheal  incision  must  be  en- 
larged,  which    exposes  to   an   irregular   incision   and   to    em 


532  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY, 

physema;  in  the  second  the  wound  in  the  soft  part  must  be 
more  or  less  deepened,  the  operation  looses  its  character  of  a 
rapid  process  or  method.  Besides,  the  wound  in  the  integu- 
ments being  very  small,  the  examination  with  the  finger  and 
eye  is  imperfect. 

For  a  long  time  I  have  adopted  a  combined  process  which 
approximates  the  rapid  method,  but  which  does  not  sacrifice 
everj'thing  to  rapidity.  It  permits,  to  a  certain  extent,  the  su- 
pervision of  the  progress  of  the  operation.  While  the  rapid- 
ity with  which  the  canula  is  introduced  quickly  arrests  the  ex- 
isting hsemorrhages,  it  enables  one  very  greatly  to  prevent 
them. 

The  cricoid  tubercle  being  recognized,  the  larynx  is  firmly 
held  between  the  thumb  and  middle  finger  of  the  left  hand, 
while  the  nail  of  the  left  index  holds  firmly  this  prominence 
and  does  not  let  it  escape.  Thus  grasped  the  larynx  is  slightly 
elevated  in  such  a  manner  that  the  trachea  forms  an  elevation 
under  the  skin.  The  incision  of  the  integument  is  made,  com- 
mencing from  the  nail  of  the  left  index,  to  the  extent  of  about 
0.64  (lYs  in.).  The  skin  only  is  divided  at  first;  the  assistant 
sponges  the  wound,  and  the  operation  is  rapidly  continued.  If 
any  large  vein  appears  it  is  pushed  aside  ;  then,  when  the  tra- 
chea is  quite  or  nearly  reached,  as  nearly  as  can  be  judged,  it 
is  punctured,  always  directing  the  knife  along  the  same  finger 
nail.  The  noise  of  the  escaping  air  announces  the  entrance 
into  the  trachea,  and  the  division  is  to  be  completed  to  the 
desired  extent. 

The  canula  may  be  introduced  without  removing  the  left 
hand  from  its  place,  and  without  the  dilator.  The  parallelism 
of  the  lips  of  the  wound  facilitates  this  step  when  the  incision 
is  well  made.  The  left  index  finger  may  still  be  introduced 
into  the  wound,  the  margin  of  the  tracheal  incision  be  caught 
by  the  nail  serving  as  a  guide  to  the  canula.  Should  one  pre- 
fer to  use  the  dilator  it  may  be  introduced,  guided  by  the  nail, 
an*^  the  canula  may  be  made  to  enter  by  the  usual  means. 


surgical  treatment.  533 

Crico-Tracheotomy. 

Several  authors  have  advised  including  the  cricoid  cartilage 
in  the  incision. 

The  late  Prof.  Hueter,  of  Greifswald,  advised  cutting  the 
cricoid  cartilage  from  below  upwards,  avoiding  the  crico-thy- 
roid  membrane,  and  extending  the  wound  if  necessary,  by  di- 
viding one  ring  of  the  trachea. 

Saint  Germain  punctures  the  ctico-thyroid  membrane 
through  the  skin,  and  divides  at  one  stroke  the  integuments, 
the  cricoid  cartilage  and  the  first  ring  of  the  trachea.  This 
process  is  of  still  more  easy  execution  than  JiigJi  tracheotomy. 
This  simplification,  however,  does  not  appear  to  me  necessary. 
High  tracheotomy  is  very  easily  performed,  and  obviates  the 
passage  of  the  canula  through  the  larynx,  interference  with 
which  may  be  a  disadvantage  to  the  vocal  cords.  Besides,  when 
when  the  patient  is  somewhat  advanced  in  age,  the  cricoid  car- 
tilage offers  resistance,  and  frequently  difficulty  is  experienced 
in  separating  its  edges ;  sometimes  this  is  even  impracticable. 
In  young  children  the  latter  inconvenience  is  not  present,  but 
one  is  not  always  sure  of  avoiding  haemorrhage.  Frightful 
hasmorrhages  do  occur. 

Choice  of  Methods. — From  what  has  been  said,  it  follows  that 
loiv  (inferieure)  tracheotomy  is  a  difficult  operation,  and  even 
dangerous  ;  it  should  always  yield  the  precedence  to  high  tra- 
cheotomy, which  I  also  prefer  to  crico-tracheotomy . 

As  to  the  rapidity  or  the  slowness  of  the  execution  I  believe 
the  rapid  operation  is  the  better ;  it  is  much  less  fatiguing,  it 
exposes  far  less  to  death  during  the  operation,  and  to  syncope; 
it  should  especially  be  preferred  when  the  patient  is  in  an  ad- 
vanced state  of  asphyxia.  It  exposes  more,  it  is  true,  to  haem- 
orrhage, but  it  permits  an  immediate  remedy  to  that  disad- 
vantage. The  introduction  of  the  canula  being  the  best  haem- 
ostatic, the  rapidity  of  the  process  permits  an  arrest  of  the 
evil  as  soon  as  it  occurs.  But,  in  order  that  it  may  be  so,  it  is 
necessary  that  the  operator  should  be  experienced  in  tracheot- 
omy.     If  haemorrhage  occurs  it  causes  delay  in  finding  the  tra- 


534  DIPHTHERIA,  CROUP  AND  TRACHEOTOMY. 

chea,  in  opening  it  and  introducing  the  canula,  and  all  is  lost; 
the  operation  is  prolonged,  and  the  patient  succumbs  to  as- 
phyxia or  haemorrhage. 

It  is  of  importance  that  physicians  who  have  not  frequent 
occasion  to  practice  tracheotomy,  should  choose  the  slow 
method  which  permits  them  to  proceed  prudently,  layer  by 
layer,  according  to  the  precept  of  Trousseau,  and  thus  avoid 
the  accidents  which  the  other  process  may  involve.  As  to 
transfixing  the  trachea,  which  has  been  charged  to  the  rapid 
process,  it  has  been  seen  more  than  once  in  the  course  of  the 
slow  operation.  We  should  concede,  however,  that  the  pro- 
cess of  fixing  by  the  tenaculum  exposes  to  this  complication 
more  than  the  other,  in  consequence,  probably,  of  the  eleva- 
tion given  to  the  trachea,  and  causing  the  posterior  wall  to  be 
no  longer  supported  by  the  cervical  column,  but  held  in  space. 

Thermic  Tracheotomy. 


4 


Several  surgeons,  engrossed  with  a  desire  to  avoid  hjemor- 
rhage,  have  endeavored  to  substitute  these  cauteries  for  cut- 
ting instruments. 

The  application  of  this  principle  to  tracheotomy  was  made 
in  1870  upon  a  child  of  16  years  of  age,  by  Amussat.  It  was  in  a 
case  of  a  foreign  body  in  the  trachea.  In  1872  Verneuil  oper- 
ated on  an  adult.  His  example  was  followed  by  Krishaber, 
Tillaux,  Voltolini,  of  Breslau,  and  Victor  Burns.  A  number  of 
these  cases  have  been  collected  in  a  valuable  monograph  by 
E.  Bourdon,  and  some  others  in  a  thesis  by  Heral.  The  gal- 
vano-cautery  was  the  instrument  employed  by  these  surgeons. 

I  shall  not  give  a  detailed  account  of  this  method,   consider-  t 

ing  that  it  is  inapplicable  to  children.     It  is,  says  Verneuil,    a  i 

method  for  the  adult.  It  is,  moreover,  impracticable  when  the 
case  is  one  of  croup.     Tracheotomy  in  this  case  is   an   opera-  j 

tion  of  urgency ;  it  should  be  performed  with  instruments 
which  may  be  always  at  hand,  and  always  ready  to  be  used. 
We  may  add  that  the  operation  by  the  galvano-cautery  often 
requires  considerable  time.  Moreover,  if  the  temperature  of  the 


SURGICAL     TREATMENT.  535 

cautery  should  be  even  a  little  too  high,  haemorrhage  will  su- 
pervene. On  several  occasions  it  was  necessary  to  finish  the 
operation  with  the  knife.  We  must  not  ignore  either  the  con- 
siderable eschars  which  are  the  consequence  of  continued  ele- 
vation of  the  temperature. 

The  serious  inconveniences  of  this  method  have  caused  it  to 
be  abandoned.  Another  has  been  sought  by  which  the  haem- 
ostatic properties  of  heat  might  be  utilized  without  its  having 
the  dangers  of  the  galvano-caustic. 

Saint  Germain  proposed  first  to  perforate  the  crico-thyroid 
membrane  with  a  pointed  actual  cautery,  heated  to  a  dull  red, 
then  to  introduce  immediately  the  dilator  and  the  canula.  The 
burning  of  the  larynx  and  the  dangers  of  letting  the  cautery  slip 
upon  the  sides  of  the  trachea  caused  the  abandonment  of  this 
process  which,  besides,  has  only  been  employed  upon  the  ca- 
daver and  the  dog. 

DeRanse  and  Muron  incline  more  to  the  operative  process 
of  Verneuil.  They  divide  the  tissues  with  a  knife  heated  in 
the  fire  instead  of  being  reddened  by  the  battery.  They  em- 
ploy for  this  purpose  the  ordinary  bistoury,  simple  table  or 
dessert  knives  with  rounded  end,  or  the  handle  of  a  spoon. 
Finally  Muron  imagined  an  instrument  formed  of  an  elliptical 
plate  of  iron  fastened  to  a  roughened  shank,  which  enabled 
the  apparatus  to  be  held  between  the  blades  of  a  forceps ;  one 
extremity  of  the  ellipse  was  narrower  and  thicker  than  the 
other. 

The  instrument  being  raised  to  a  white  heat,  the  broader 
end  is  applied  to  the  skin,  about  o.oi  (Vs  in.)  below  the  cricoid 
cartilage;  the  division  of  the  integuments  and  superficial  parts  is 
then  effected.  The  temperature  of  the  instrument  during  this 
time  having  fallen  to  a  dull  red,  it  is  turned  and  the  operation 
continued  with  the  thick  narrow  end.  The  operator  proceeds 
cautiously,  drawing  aside  the  tissues,  if  it  is  thought  best,  with 
the  aid  of  a  spring  forceps  in  such  a  manner  as  to  stop  as  soon 
as  the  trachea  is  recognized  by  its  white  surface.  It  was  recom- 
mended to  avoid  touching  this  air  tube  with  the  cautery  for 
fear  of  subsequent  necrosis  ;  the  tube  is  opened  with  the  knife 


53^  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

and  the  canula  introduced.  A  fundamental  precept  of  this 
process  consists  in  dividing  the  deep  tissues  with  the  cautery 
at  a  dull  red  heat.  It  is  known  that  this  temperature  exerts  pow- 
erful haemostatic  properties,  while  the  white  red  causes  ha:m- 
orhage.  This  operative  process,  which  already  constitutes  an 
advance  beyond  the  preceding  one,  has  not  been  applied  to 
man.  It  is,  therefore,  difficult  to  judge  of  it.  We  may,  how- 
ever, foresee  all  the  precautions  that  it  requires.  It  is  neces- 
sary to  know  how  to  get  the  exact  degree  of  temperature  at 
which  one  may  prevent  haemorrhage.  Is  not  the  patient  ex- 
posed to  considerable  eschars  which  retard  and  make  the  cica- 
trization of  the  wound  irregular? 

Following  this  line,  Saint  Germain  has  simplified  and  ren- 
dered this  process  easier  of  application.  He  uses  a  bistoury 
rounded  like  a  table  knife,  and  therefore  not  probe-pointed. 
This  able  surgeon  says : 

"I  attach  to  it,  at  the  heel,  to  an  extent  of  about  0.015  (^/s  in.,)  a  band  of  moist 
thread.  This  device  is  intended  to  enable  me  to  hold  the  knife  in  my  hand  without 
burning  me.  That  done  I  hold  it  in  the  jet  of  an  eSlipile  flame,  or  alchohol  lamp, 
and  bring  it  to  a  white  heat;  then  I  plunge  it  in  perpendicularly  on  a  level  with  the 
crico-thyroid  membrane.  It  penetrates  the  tissues  with  the  greatest  ease,  and  the 
sensation  of  resistance  overcome,  when  it  has  arrived  within  the  larynx,  is  still  more 
distinct  than  with  the  ordinary  bistoury.  This  first  step  being  executed  I  proceed  as 
I  have  already  described,  and  cut  through  {scie,  saTv)  the  cricoid  and  two  rings  of  the 
trachea;  then  I  cut  obliquely  in  such  a  manner  as  to  divide  the  integument  a  little 
more  extensively  than  the  trachea  itself.  I  have  applied  this  process  in  one  case, 
upon  a  child  of  from  three  to  four  yea'-s,  and,  I  should  say,  it  succeeded  perfectly  in 
the  sense,  first  of  having  had  no  bleeding,  and  that  we  were  able  to  complete  our 
operation  entirely;  and  secondly,  when,  after  eight  days  the  child  sank  under 
diphtheritic  invasion,  I  was  able,  by  post  mortem  examination,  to  exhibit  his  lar- 
ynx to  the  Societe  de  Chirurgie  absolutely  free  from  cauterization,  either  of  the 
posterior  wall  or  of  the  sides.  It  has  been  well  observed  that  the  heat  may  ex- 
ercise a  deleterious  influence  upon  the  vocal  cords ;  I  patiently  await  a  case  of 
success  by  this  process,  and  I  hope  to  remove  the  objection  which  has  been  offered 
by  exhibiting  a  speaking  patient." 

In  fact,  in  order  to  render  an  opinion  we  must  aA'ait  the  re- 
sults of  a  larger  experience. 

In  the  mean  time  we  may  present  several  objections.  In  the 
first  place,  the  direct  puncture   of  the  larynx,   made   with  the 


SURGICAL    TREATMENT.  537 

bistoury,  which  already  occasions  serious  disturbance  when  the 
instrument  goes  astray,  will  be  still  more  dangerous  when  it 
shall  be  performed  with  the  aid  of  the  cautery.  It  was  to 
avoid  this  difficulty  that  Saint  Germain  attacked  primarily 
[d'  emblee)  the  crico-thyroid  membrane,  the  larynx  being  more 
superficial  and  more  easily  held  than  the  trachea.  But  then 
the  second  objection  presents  itself,  that  of  burning  the  larynx; 
that  is  one  of  no  less  importance.  These  disadvantages  were 
fully  appreciated  by  this  able  surgeon,  and  he  has,  for  the 
present  at  least,  abandoned  this  process. 

Accidents  of  Tracheotomy. 

The  difficulties  which  arise  at  every  step  in  the  performance 
of  tracheotomy  I  have  pointed  out.  If  the  operator  has  not 
reached  a  position  in  experience  from  which  he  can  meet 
them,  they  become  so  many  sources  of  real  accidents,  capable 
of  destroying  the  patient  suddenly  by  syncope  or  by  asphyxia. 

Syncope  has  for  its  origin  the  haemorrhage,  or  sometimes 
simply  the  depression  of  the  powers  which  renders  the  patient 
incapable  of  surviving  the  injury  of  the  operation. 

Asphyxia  is  the  termination  of  all  causes  which  prolong  the 
operation  or  retard  the  introduction  of  the  canula.  The  inten- 
sity of  the  dyspnoea,  the  uncomfortable  position  in  which  the 
patient  is  held,  unitedly  demand  a  prompt  supply  of  air. 

These  various  accidents  are  :  hcBiuorrhage  which,  according 
to  the  manner  in  which  it  acts,  may  produce  asphyxia  as  well 
as  syncope,  and  the  defective  incision  of  the  tracJiea.  We  should 
add  thereto  _/h:/.y^  membranes  in  the  trachea,  traumatic  emphy- 
sema, and  wound  of  the  oesophagus. 

Hemorrhage. 

Haemorrhage  shows  itself  at  the  time  of  the  operation  or  a 
short  time  afterwards.  It  is,  accordingly,  primary  or  second- 
ary. 

Primary  Hceniorrhage. — It  is  almost  always  venous.    Arterial 


53^  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

haemorrhage  is  extremely  rare,  and  presents  nothing  special.   I 
will  not  insist  upon  the  gravity  of  a  wound  of  the  carotid  or  of 
the  innominate  trunk.      It  has  already  been  shown   that   these 
accidents  have  occurred.     The  veins  most  frequently  wounded 
are  branches  of  the   thyroid  plexus.     The   division   of  one  of 
the  internal  jugular  veins  is  so  exceptional  that  it  is  sufficient 
to    point  out  its  possibility.     The  slow   operation  has  the  ad- 
vantage of  rendering  the   injury   of  important  vessels   uncom- 
mon ;     we   must    not    think,    however,    that    they    are    always 
avoided.     It  is  sometimes   difficult  not  to  wound   some   deep 
vessel  in    spite  of  the  greatest  care.  In  proceeding  rapidly  one 
runs  greater  risk,  but  it  is  remedied  by   the  prompt  introduc- 
tion of  the  canula,  which  arrests,  as    by  enchantment,   the  es- 
cape of  blood,    as   well    by  the  compression  which  the   canula 
exerts  upon  the  patulent  vascular  orifices  as  by  the   equaliza- 
tion of  the    circulation.     Inferior  tracheotomy   exposes  much 
more  to  hccmorrhage  than  the  high  operation;  the  same  is  true 
of  too  lengthy  incisions,   and  of  dividing   constrictions  down- 
wards.    It  is  not  rare,  after  the  trachea  has  been  exposed  with- 
out trouble,  with  the  last  stroke  of  the  knife,  intended  only  to 
enlarge  the  incision,  to  encounter  a  thyroid  vein. 

The  section  of  a  vessel  gives  rise  to  a  jet  of  blood,  in  size 
proportioned  to  the  caliber  of  the  vein.  If  the  trachea  is 
already  opened,  the  blood  runs  into  it  and  provokes  cough 
which  expels  it  forcibly,  and  sprinkles  it  upon  the  operator  and 
the  assistants  hke  a  shower.  It  is  a  spectacle  most  dramatic  ; 
the  fate  of  the  patient  is  decided  in  a  few  moments ;  every- 
thing depends  upon  the  time  that  is  occupied  in  introducing 
the  canula.  Besides,  when  the  vessel  is  important,  the  inter 
vention  of  this  instrument  may  be  insufficient.  9 

Sanguineous  oozing  sometimes  comes  from  the  thyroid  body. 
When  the  incision  is  on  the  isthmus,  this  being  most  frequently 
very  thin  ;  it  bleeds  but  little  if  at  all.  When,  as  an  exception, 
it  is  voluminous,  or  the  incision  is  made  upon  one  of  the  lobes 
of  the  gland,  the  result  is  a  heemorrhage  no  longer  in  jets  but 
like  a  wave.  The  most  common  is  that  which  occurs  during 
the  operation  at  the  moment  of  the  division    of   a  vessel.      Or, 


ACCIDENTS    OF    TRACHEOTOMV.  539 

• 

again,  it  may  occur  only  a  few  minutes  after,  when  the  opera- 
tion has  been  nearly  bloodless.  The  rapid  process  is  particu- 
larly liable  to  this  condition.  But  should  the  division  of  integ- 
uments and  trachea  be  made  by  a  single  stroke,  the  concur- 
rence of  asphyxia  and  the  operative  celerity  prevents  all  im- 
mediate escape  of  blood,  even  when  an  important  vessel  may 
have  been  cut.  But,  after  the  respiration  has  been  restored, 
the  vessels  bleed  freely.  When  supervening  in  spite  of  the 
presence  of  the  canula,  this  haemorrhage  is  very  serious  and 
often  fatal. 

When  the  sanguineous  discharge  comes  on  after  the  intro- 
duction of  the  canula,  and  persists  after  this  step  of  the  opera- 
tion, the  blood  escapes  externally,  most  frequently  by  the  in- 
ferior angle  of  the  wound  or  by  the  canula;  the  haemorrhage  is 
visible,  and  one  may  meet  it  by  appropriate  means.  In  other 
cases  the  blood  escapes  externally  and  internally.  Then  it  is 
we  may  have  to  combat  a  most  formidable  accident.  Besides, 
by  entering  the  air-passages,  the  blood  excites  cough  which 
expels  it  partly  through  the  tube,  but  the  concussion  revives 
the  haemorrhage,  and  so  on  continuously.  Ordinarily  the 
cough  becomes  quiet  in  a  short  time,  and  the  bleeding  ceases  , 
but  it  does  also  occur  that  the  escape  continues  till  the  child 
sinks  from  anaemia  or  from  asphyxia.  All  the  causes  which 
induce  cough  concur  in  aggravating  haemorrhage.  The  most 
powerful  is  the  presence  of  floating  false  membranes  behind 
the  canula.  I  reported  the  case  of  a  patient  who,  finding  him- 
self attacked  with  a  severe  haemorrhage,  coughed  violently  and 
caused  a  rattling  behind  the  tube,  which  indicated  the  pres- 
ence of  a  false  membrane.  Notwithstanding  the  extraction  of 
numerous  fragments,  it  was  impossible  to  arrest  the  discharge  ; 
the  child  became  cold,  pale  and  sank. 

Asphyxia  is  also  a  result  of  blood  entering  the  bronchial 
tubes.  The  cough  does  not  always  suffice  ,tov  empty  the  chest, 
the  dyspnoea  augments,  anxiety  increases,  the  patient  makes 
extraordinary  efforts  to  expel  this  new  obstacle,  and  succumbs 
when  the  small  bronchiae  become  filled.  During  the  struggle 
auscultation  detects  fine,  Hmited  rales  in  the  inferior  portion  of 


540  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

• 

both  lungs.  When  the  haemorrhage  decreases,  and  the  dysp- 
noea diminishes,  all  goes  well.  The  expectoration  contains 
only  traces  of  blood  during  twenty-four  or  thirty-six  hours 
after  the  cessation  of  haemorrhage. 

Asphyxia  may  occur  suddenly  when  the  blood  expelled 
through  the  tube  ceases  its  obstruction.  I  have  reported  the 
history  of  a  case  which  fell  as  if  struck  by  lightning  a  few  min- 
utes after  the  introduction  of  the  canula.  I  discovered  that 
the  inner  tube  was  filled  by  a  plug  of  coagulated  blood  and 
fibrin  introduced  from  the  inside  by  the  force  of  the  cough. 
The  entire  removal  of  the  tube,  quickly,  could  alone  restore 
life.  These  facts  are  fortunately  rare,  but  it  is  important  to  be 
aware  of  them;   they  may  serve  as  a  key  to  difficulties. 

The  amount  of  the  sanguineous  discharge  is  variable  ;  some- 
times it  is  insignificant.  I  have  seen  it  reach  six  to  eight 
ounces. 

When  the  termination  is  favorable  the  haemorrhage  ceases 
most  frequently  not  to  return  ;  in  other  cases  it  returns  in  sev- 
eral attacks,  either  every  day  or  at  intervals.  One  patient 
could  not  remain  relieved  of  the  canula  without  a  stream  of 
blood  appearing.  In  the  intervals  between  the  dressing  there 
was  sometimes  a  slight  discharge  through  the  canula. 

Seeondary  Hcemorrliage. — Haemorrhage  occurs  not  only  at 
the  time  of  the  operation.  It  is  not  very  uncommon  to  see  bloody 
discharges  appear  at  the  time  of  changing  the  canula,  even 
when  the  operation  has  not  been  especially  bloody;  again,  it 
may  occur  at  a  still  later  period,  at  the  fifth,  seventh,  eleventh 
or  fifteenth  day.  The  most  frequent  time  is  the  first  dressing. 
I  have  collected  twenty-two  cases  of  haemorrhage  of  this  kind, 
and  Andre,  Boeckel  and  Wilks  each  report  one.  These  haem- 
orrhages occur  externally  or  internally.  They  are  often  less 
abundant  than  the  primary.  Nevertiieless  Wilks  speaks  of  a 
patient  who  sank  under  a  sudden  haemorrhage  fifteen  days 
after  tracheotomy.  In  the  twenty-two  cases  of  secondary 
haemorrhage,  the  operation  was  quite  bloody  in  thirteen  ;  in 
three  the  details  were  omitted. 

Secondary  haemorrhages  are    due    to    several    causes.     The 


ACCIDENTS    OF    TRACHEOTOMY.  54 1 

most  frequent  is  the  reopening  of  a  vessel  which  had  ceased  to 
bleed  by  being  compressed  by  the  canula,  but  whose  obhtera- 
tion  was  not  permanent.  It  opens  at  the  time  of  removing  the 
tube.  The  same  disposition  may  persist  for  several  days.  The 
necessary  manipulations  in  the  dressing  constitute  the  second 
order  of  causes,  either  by  removing  the  false  membranes  or 
eschars,  or  by  the  introduction  of  the  canula,  a  vessel  may  be 
wounded  or  one  opened  which  had  been  momentarily  occluded. 
This  mechanism  has  been  shown  in  one  case. 

Compression  exerted  by  the  canula  may  become  a  source  of 
haemorrhage  by  ultimately  ulcerating  the  walls  of  the  vessels 
spared  by  the  knife. 

[Secondary  hsemorrhage  from  the  innominate  artery,  resulting  from  ulceration 
due  to  the  pressure  of  the  canula,  proved  fatal  in  two  cases  reported  to  the  An- 
atomical Society  of  Paris,  and  referred  to  in  the  British  Medical  Journal  for  April, 
1881  Hsemorrhage  from  the  tracheal  mucous  membrane  proved  fatal  in  one  of 
my  own  cases,  by  giving  rise  to  bronchial  pneumonia. — Ashhurst^ 

Finally,  diphtheritic  poisoning,  which  is_  of  itself  a  cause  of 
hsemorrhage  into  the  tissues  which  have  not  suftered  from  op- 
eration, acts  still  more  energetically  upon  those  of  the  wound. 

When  the  loss  is  but  slight  it  produces  no  unfavorable  con- 
sequence, but  if  it  has  been  copious  it  increases  the  disposition 
to  anaemia,  already  so  decided  in  diphtheritic  patients,  and  ag- 
gravates the  prognosis  even  when  it  does  not  directly  cause 
annoying  accidents.  In  twenty-two  cases  of  secondary  haemor- 
rhage, twelve  induced  death  rapidly,  or  through  the  influence 
of  anaemia.  Haemorrhages  should  be  energetically  suppressed. 
In  case  of  arterial  injury  one  should  endeavor  to  ligate  imme- 
mediately  both  ends  of  the  vessel.  This  operation  is  not  very 
difficult  if  one  has  to  deal  with  a  transverse  artery  such  as  the 
thyroideal  of  Neubauer. 

When  it  is  a  case  of  venous  lesion  produced  at  the  begin- 
ning of  the  operation,  the  best  means,  the  means  almost  infal- 
lible in  overcoming  it,  is  the  introduction  of  the  canula.  If, 
however,  haemorrhage  occurs  before  this  time  to  an  annoying 
degree,  one  may  apply  with  advantage  the  haemostatic  for- 
ceps at  the  point  where  the  blood  escapes. 


542  DIPHTHERIA,    CROUP    AN'D    TRACHEOTOMY. 

Pean  uses  this  method  with  advantage  in  tracheotomy,  as  in 
many  other  operations 

I  have  had  made  by  Collin  small  forceps  fashioned  after  the 
model  of  dissecting  forceps;  their  extremities  are  widened  in 
the  form  of  a  T  so  as  to  sieze  a  certain  amount  [masse)  of 
tissue. 

Avoid  the  application  of  the  perchloride  of  iron  to  the  in- 
terior of  the  wound  ;  it  produces  a  black  coagulum  which  later 
penetrates  into  the  trachea  and  increases  the  asphyxia. 

If  the  haemorrhage  arise  from  a  lesion  of  the  thyroid  body, 
compression,  exercised  by  the  finger  or  by  the  blunt  hooks, 
suffices,  most  frequently,  for  its  arrest.  The  introduction  of 
the  canula  does  not  always  stop  the  sanguineous  discharge. 
Several  processes  may  be  put  intq.  operation.  If  it  be  slight, 
a  little  pressure  upon  the  wound  is  sufficient  in  all  cases.  The 
best  expedient  consists  in  dressing  the  inferior  angle  of  the 
wound  with  bits  of  agaric,  or  better,  wadding,  introduced  un- 
der the  patch  of  oiled  silk  or  gummed  cloth.  When  the  first 
bit  is  saturated  with  blood,  a  second  is  added  and  so  on  until 
the  haemorrhage  is  arrested.  It  forms  a  bloody  crust,  com- 
presses the  wound  slightly,  and  stops  the  bleeding  before  there 
is  occasion  to  apply  a  large  quantity  of  wadding.  This  sub- 
stance absorbs  with  great  facility,  and  ought  for  this  reason  to 
be  preferred  to  agaric. 

If  the  haemorrhage  is  more  intense,  direct  compression  of 
the  inferior  angle  of  the  wound  with  the  finger  may  be  useful; 
but  as  this  manoeuver  is  fatiguing  to  the  patient  as  also  to  the 
physician,  the  finger  is  withdrawn  when  the  haemorrhage  di- 
minishes, and  we  have  recourse  to  pledgets  of  wadding. 

If  this  method  does  not  succeed,  we  apply  on  the  wound  a 
dossil  of  lint  saturated  with  perchloride  of  iron.  But  this  is  a 
very  painful  application,  and  may  be  the  starting  point  of  an 
abscess.  It  has  also  been  advised  to  withdraw  the  canula  in 
order  to  seek  to  ligate  the  divided  vessel.  This  is  a  practice 
which  we  must  guard  against  following,  we  would  thus  abandon 
the  only  effectual  compressive  means  to  devote  ourselves  to  a 
search,  very   long  if  not    fruitless,    during   which    the    patient 


ACCIDENTS    OF    TRACHEOTOMY.  543 

would  have  ample  time  to  expire.  Better  replace  the  canula 
by  one  larger.  We  obtain  frequently  by  this  plan  excellent 
results.  If  it  does  not  suffice,  we  endeavor  to  place  one  or 
more  haemostatic  forceps  upon  the  divided  vascular  extremi- 
ties, and  replace  the  tube  besides.  In  case  of  impossibility  we 
hold  the  trachea  open  with  a  dilator.  All  these  means,  the 
canula  excepted,  are  applicable  only  to  discharge  of  blood  oc- 
curring by  the  external  orifice  of  the  wound  ;  it  is  necessary, 
therefore,  in  case  of  internal  haemorrhage,  to  seek  a  process 
which  possesses  rapid  and  general  haemostatic  action;  the  em- 
ployment of  alcohol  in  large  doses  combines  these  conditions. 
While  it  renders  great  service  in  the  large  haemorrhages,  es- 
pecially in  those  following  delivery,  this  agent  is  of  excellent 
use  in  the  sanguineous  losses  which  complicate  tracheotomy. 
I  have  cited  some  cases  in  which  the  use  of  the  wine   of  Bap-- 

o 

noles  in  a  large  quantity  was  followed  by  the  immediate  arrest 
of  the  haemorrhage;  rum,  in  doses  of  6o.  to  8o.  (2  to  2'/^  5), 
has  also  produced  remarkable  results.  Alcohol  should  be 
given  largely;  full  doses  are  surest;  one  need  not  fear  going 
too  far. 

Persons  are  much  concerned  about  the  results  which  may 
follow  the  entrance  of  blood  into  the  trachea,  and  have 
advised  as  a  preventive  measure  the  aspiration  of  the  effused 
fluid,  either  with  the  mouth  directly  or  with  the  elastic  tube. 
This  method  is  very  popular  in  England  and  in  Germany.  Many 
physicians  of  these  countries,  among  others,  Roserand  Hueter, 
so  much  dread  this  accident  that  they  recommend  not  to  open 
the  trachea  till  after  the  cessation  of  haemorrhage  ;  the  effects 
following  the  introduction  of  the  canula  is  to  them  still  little 
known.  However,  Dr.Durham,  of  London,has  protested  against 
this  practice  of  his  countrymen,  and  showed  that  the  want  of 
air  exposes  patients  to  far  greater  dangers  than  the  presence 
of  blood  in  the  bronchial  tubes.  Besides  the  suction  is  useless. 
When  the  sanguineous  exudation  is  comparatively  slight,  the 
efforts  of  coughing  quickly  expel  all  that  has  been  diverted 
into  the  air-passages  ;  this  manipulation  is  then  superfluous.  If 
the  hc-emorrhage  is  abundant  and  continued,   aspiration   is  un- 


544  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY 

able  to  relieve  the  bronchi,  the  blood  that  is  removed  being 
constantly  resupplied.  There  is  no  time  to  intercede  with  any- 
chance  of  success,  only  after  the  haemorrhage  has  ceased,  if 
the  patient  has  been  able  to  survive  so  long.  Moderate  cough- 
ing should  be  excited,  and  if  the  child  has  retained  some 
strength  and  still  reacts,  he  will  expel  the  excess  of  liquid 
contained  in  the  bronchi. 

The  position  given  to  the  patient  must  not  be  neglected.  So 
long  as  the  loss  is  moderate  he  may  sit  upon  his  bed  supported 
by  pillows  in  order  to  avoid  the  entrance  of  the  fluid  into  the 
trachea.  On  the  contrary,  if  syncope  appears  imminent  he  is 
laid  down,  and  sinapisms  are  directed  to  be  placed  upon  the 
body,  at  the  same  time  that  the  face  is  vigorously  slapped  with 
a  towel  wet  with  fresh  water.  But  why  dread  the  syncope 
since  it  would  have  the  effect  very  likely  of  arresting  the 
hsemorrhiige  ?  This  objection  might  have  some  weight  if  it 
were  a  case  of  ordinary  haemorrhage,  but  in  a  disease  infectious 
like  croup,  and  in  which  sudden  death  is  not  very  rare,  we 
should  dread  syncope  and  avoid  it  by  all  means.  In  order  to 
prevent  the  blood  entering  the  respirarory  passages.  Dr.  Hil- 
ton advises  placing  the  patient  in  the  prone  position,  when  one 
has  reason  to  fear  that  accident.  It  is  useless  to  point  out  the 
folly  and  the  danger  of  this  practice  ;  the  prompt  introduction 
of  the  tube  is  preferable  to  it  in  all  cases. 

Imperfect  Incisions  of  the  Trachea. 

A  median  tracheal  incision  of  proper  dimensions,  that  is, 
about  0.015  (^/s  in.)  long,  at  a  sufficient  height,  is  that  which 
we  should  endeavor  to  obtain.  One  or  several  of  these  condi- 
tions, and  sometimes  all,  are  deficient.  It  happens  in  some 
cases  that  the  air  comes  hissing  through  the  wound  at  a 
moment  least  expected.  The  trachea  has  been  wounded  unin- 
tentionally by  too  deep  a  cut  with  the  knife  before  the  air 
tube  was  exposed.  This  mishap  is  sufficiently  common  with 
beginners,  and  startles  them  very  much.  Two  plans  may  be 
adopted  to  obviate  the  consequences,  that  is  to  say,  to  prevent 


ACCIDENTS    OF    TRACHEOTOMY.  545 

the  traumatic  emphysema,  which  would  result  from  a  too  long 
continued  passage  of  the  air  through  the  tissues.  The  first 
consists  in  placing  the  left  index  finger  over  the  little  opening, 
continuing  the  operation,  exposing  the  trachea  and  finally  en- 
larging the  small  incision. 

In  the  second,  we  introduce  directly  into  the  wound  a  probe- 
pointed  bistoury,  and  then  divide  the  strictures.  If  we  find  it 
without  difficulty,  and  that  the  incision  is  straight  and  in  the 
median  line,  the  danger  is  easily  repaired,  but  it  does  occur 
that  this  prolongation  is  made  obliquely  or  in  a  different  direc- 
tion from  the  first  incision ;  the  result  then  is  an  incision  in  an 
irregular  line.  It  also  happens  that  the  accidental  orifice  is 
not  easily  found  ;  it  may  be  even  undiscoverable.  In  that 
case  a  second  puncture  is  made  and  extended  by  an  incision  ; 
the  trachea  is  opened  then  twice.  From  these  errors  arise 
sometimes  emphysema,  at  others,  difficulties  in  the  introduc- 
tion of  the  tube. 

An  incision  too  short  renders  the  introduction  of  the  tube  im- 
possible. The  incision  is  then  extended  with  the  probe- 
pointed  bistoury,  sometimes  even  on  the  dilator.  From  this 
come  irregular  or  V-shaped  incisions,  which  often  cause  insur- 
mountable difficulties  in  the  matter  of  introducing  the  tube. 

An  incision  too  long  permits  the  canula  to  pass  easily,  but 
is  frequently  accompanied  with  haemorrhage  ;  it  is  seldom  that 
the  last  stroke  of  the  knife  does  not  injure  some  important  ves- 
sel. If  this  misfortune  is  avoided  it  may  be  only  to  fall  into 
another.  The  canula  is  retained  with  difficulty  in  incisions  of 
this  kind.  However  tight  the  tapes  may  be  tied,  the  instru- 
ment escapes  from  the  wound  of  itself  at  the  end  of  some 
hours,  or  in  less  time.  If  it  is  not  replaced  at  the  time  there 
is  danger  of  asphyxia  or  emphysema.  The  only  means  of  pre- 
venting the  recurrence  of  this  accident  is  the  introduction  of  a 
longer  tube. 

A  lateral  incision  is  produced  when  the  trachea,  being  very 
mobile  and  displaced  by  the  finger,  is  punctured  upon  the  side, 
while  the  skin  has  been  divided  in  the  median  line.  If  the  op- 
erator then    withdraws  his  finger   the   trachea    returns   to   its 


546  DIPHTHERIA,  CROUP  AND  TRACHEOTOMY. 

place  ;  the  incision  is  hid  under  the  soft  parts  and  becomes  in- 
accessible. The  efforts  at  introduction  of  the  canula  are  fruit- 
less, the  dilator  even  does  not  enter  the  trachea.  In  these  at- 
tempts both  instruments  produce  separation  of  the  tissues  ;  the 
canula  is  placed  in  front  of  the  trachea,  and,  to  conclude,  the 
patient  suffocates. 

Not  discovering  again  the  tracheal  incision,  the  operator 
makes  another  which  is  parallel  to  the  first,  at  other  times  ob- 
lique, so  as  to  form  a  V  at  the  superior  or  at  the  inferior  angle. 
The  introduction  of  the  canula  by  this  second  passage  is  very- 
difficult,  often  impossible.  When  it  is  effected,  another  gaping 
incision  remains  through  which  the  air  escapes  into  the  con- 
nective  tissue  where  it  soon  produces  emphysema. 

All  incision  too  low  exposes  to  the  same  dangers  as  one  too 
long. 

Afi  incision  too  high  constitutes  laryngotomy  instead  of  tra- 
cheotomy. A  mistake  in  the  situation  of  the  land  mark  (the 
cricoid  tuburcle)  has  caused  more  than  once  the  division  of 
the  thyroid  cartilage  in  its  entire  length.  In  this  case  the  in- 
troduction of  the  canula  is  nearly  always  impossible;  the  pa- 
tient dies  asphyxiated.  When  one  does  succeed  in  introducing 
the  canula  it  is  at  the  cost  of  considerable  laceration  which 
does  not  improve  the  matter. 

l^hQ  perfotation  of  the  trachea  through  and  through  (transfix- 
ing) has  been  reported  by  several  authors.  Millard  cites  two 
cases,  Peter  reports  one.  [I  believe  I  saw  one  case  of  this 
kind.] 

Of  these  three  patients,  only  one  survived,  the  other  two 
died  asphyxiated  during  the  operation.  I  have  met  also  three 
such  cases  ;  all  were  fatal.  This  accident  is,  therefore,  one  of 
the  most  serious  that  can  happen  during  the  operation.  In 
fact,  it  destroys  rapidly  by  asphyxia,  or  gives  rise  to  emphy- 
sema. 

In  the  first  case  it  may  happen  that  the  two  openings,  being 
wide,  the  canula  passes  through  them  both  and  the  extremity 
lodges  posteriorly  in  the  peritracheal  connective  tissue,  or  in 
front  of  the  oesophagus.     The  patient  is  suddenly  suffocated. 


ACCIDENTS    OF    TRACHEOTOMY.  547 

In  the  second  case,  the  posterior  opening  being  too  small  to 
transmit  the  canula,  it  enters  the  trachea.  But  a  certain 
amount  of  air  escapes  by  the  second  incision  and  is  diffused 
into  the  connective  tissue. 

The  operation  made  with  the  tenaculum  is  the  most  com- 
mon cause  of  transfixion  of  the  trachea. 

False  Membranes  of  the  Trachea. 

When  one  operates  on  a  patient  having  the  trachea  lined  with 
thick  false  membranes,  these  sometimes  cause  serious  accidents. 
In  puncturing  the  trachea  the  bistoury  would  penetrate  a  thicker 
wall  than  usual.  Most  frequently  the  instrument  passes  beyond, 
but  sometimes  it  remains  on  this  side  of  the  membrane  ;  the 
hissing  is  not  heard ;  one  believes  himself  in  error;  another 
puncture  is  made,  hence  two  incisions.  It  happens  also  that 
the  trachea  only  being  incised,  the  canula  separates  and  crowds 
the  membrane  before  it,  and  remains  outside  the  respiratory 
cavity.  The  air  cannot  penetrate  ;  asphyxia  supervenes  rap- 
idly if  the  error  is  not  recognized,  which,  moreover,  is  very 
difficult.  One  is  rather  tempted  to  suspect  a  false  route,  the 
canula  is  withdrawn  and  again  introduced  in  the  same  place 
without  obtaining  any  favorable  change.  Dr.  Jacobi,  of  New 
York,  reports  a  case  of  this  kind.  If  the  false  membrane  is  re- 
sistant it  opposes  the  entrance  of  the  canula.  When  one  is 
quite  certain  of  having  incised  the  trachea,  he  must  direct  the 
dilator  into  the  wound  upon  the  left  index ;  if  there  is  a  false 
membrane  plugging  the  wound  it  is  seen,  and  it  may  be  seized 
and  extracted  with  the  forceps.  I  have  seen  this  procedure  suc- 
ceed in  three  cases,  in  causing  the  canula  to  enter  after  several 
fruitless  attempts.  The  following  case  is  an  interesting  exam- 
ple of  the  kind  :  I 

The  child  being  operated  on  was  four  and  a  half  years  old,  in  the  third  period  the 
trachea  being  punctured  and  incised  I  was  surprised  at  not  hearing  the  characteristic 
sound.  The  finger,  introduced  into  the  wound,  enabled  me  to  ascertain  that  the  tra- 
chea was  incised.  I  hastened  to  introduce  the  canula;  the  air  still  did  not  pass  ;  res- 
piration was  suspended;  the  child  fell  into  a  state  of  apparent  death.  Inflaiions 
through  the  tube  were  at  first  fruitless.     However,  before  long  they  were  followed  by 


548  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

spontaneous  inspirations.  The  child  revived,  But  in  a  few  minutes  suspension  of 
respiration  returned.  I  then  withdrew  the  canula,  introduced  the  dilator,  and  I  saw 
a  large  false  membrane  completely  occluding  the  opening  in  the  trachea.  I  immedi- 
ately removed  it  with  the  aid  of  forceps.  It  adhered  strongly  by  its  lower  extremity. 
Its  dimensions  were  0.05  (2  in.)  in  length,  and  0.02  (^/s  in.)  in  breadth. 

Under  other  circumstances  the  false  membrane  is  largely 
separated  and  thrust  back  by  the  canula  which  detaches  it, 
and  it  falls  into  the  inferior  part  of  the  trachea  which  it  closes, 
and  the  patient  immediately  sinks  from  asphyxia. 

In  a  similar  case  the  respiration  ceased  at  the  moment  of 
the  introduction  of  the  canula.  It  returned  after  a  violent  ex- 
piration had  thrown  a  considerable  patch  of  false  membrane 
into  the  canula  which  was  removed  by  the  forceps ;  another 
smaller  piece  followed  soon  after,  and  the  respiration  became 
perfectly  free.  False  membranes,  formed  in  the  trachea  or  in 
the  bronchi,  may  cause  asph}'xia  by  a  different  mechanism. 
When  they  are  detached  they  are  carried  by  expiration,  and 
principally  by  the  cough,  towards  the  exterior.  They  then 
present  themselves  at  the  extremity  of  the  canula,  or  become 
engaged  in  the  inner  tube.  Dyspnoea  with  true  paroxysms  of 
suffocation,  even  asphyxia,  are  the  result  of  these  qiigrations. 
The  respiration  becomes  embarrassed,  noisy,  tl:e  canula 
whistles  or  causes  a  flapping  sound  like  a  valve  or  waving 
body;  the  cough  becomes  incessant  and  suffocative.  If  the 
false  membrane  is  small  and  loose,  a  fit  of  coughing  expels  it, 
and  the  respiration  becomes  established  ;  but  if  it  should  be 
adherent  by  one  extremity,  and  rather  large,  the  respiratory 
disturbance  becomes  aggravated,  the  face  becomes  anxious 
and  red,  and  the  signs  of  asphyxia  appear.  At  this  point  it 
does  happen  again  that  a  violent  fit  of  coughing  may  detach 
the  concretion  and  expel  it  through  the^anula,  but  the  pow- 
ers of  nature  are  not  always  sufficient.  It  is  in  such  cases  that 
prompt  relief  becomes  necessary,  under  penalty  of  inevitable 
death. 

What  is  to  be  done  in  such  cases  ?  If  the  suffocative  attacks 
are  moderate,  we  commence  by  irritating  the  tracheal  mucous 
membrane  by  means  of  a  feather  passed  through   the    canula. 


ACCIDENTS    OF    TRACHEOTOMY.  549 

If  this  measure  does  not  succeed  we  may  introduce  into  the  can- 
ula  the  tracheotomy  forceps  in  search  of  the  false  membrane 
There  are  several  forms  of  these  forceps  ;  the  one  which  suits 
me  the  best  is  that  of  Luer. 

This  attempt  may  be  made  and  be  repeated  a  number  of 
timer,  before  meeting  with  any  success.  Often  it  fails  entifely. 
It  is  a  means  from  which  little  is  to  be  expected.  If  asphyxia 
is  imminent,  the  only  thing  to  do  is  to  remove  the  canula. 

Sometimes  this  simple  act  is  sufficient  to  excite  the  expul- 
sion of  the  false  membrane ;  in  the  opposite  case  we  introduce 
the  dilator ;  entrance  of  air  into  the  trachea  widely  opened, 
gives  rise  to  a  paroxysm  of  coughing,  frequently  ending  in 
the  expulsion  of  the  foreign  body.  Sometimes  one  sees,  float- 
ing at  the  bottom  of  the  wound,  the  false  membrane ;  it  is  then 
easy  to  seize  it  with  the  forceps  and  extract  it.  If  it  is  loose, 
the  extraction  is  easy  ;  but  we  may  also  find  that  it  is  still  ad- 
herent to  the  trachea  by  one  of  its  extremities  ;  then  it  is  nec- 
essary to  use  sufficient  force  to  remove  it  piecemeal.  We  thus 
may  bring  out  pieces  0.05  or  0.06  (2  in.)  or  more  in  length. 

If  the  paroxysms  of  cough,  excited  by  the  dilator,  do  not 
throw  out  the  exudate ;  if  it  is  not  visible,  one  finds  it  expedi- 
ent occasionally  to  introduce  the  forceps  into  the  trachea ;  re- 
newed fits  of  coughing  are  thus  excited,  and  we  may  succeed 
in  seizing  some  fragments  of  false  membrane. 

These  expedients  should  soon  produce  satisfactory  results  ; 
otherwise  it  is  useless  and  even  dangerous  to  continue  them  ; 
they  contuse  the  edges  of  the  wound;  and,  moreover,  the  cold 
air  which  they  introduce  freely  into  the  trachea,  may  be  the 
starting  point  of  one  of  the  pulmonary  inflammations  which 
carry  off  so  many  patients  attacked  with  croup.  If  they  re- 
main unsuccessful,  we  hasten  then  to  introduce  the  canula. 
This  means  is  still  more  powerful  than  the  preceding  ;  we  con- 
stantly see  the  false  membrane  driven  violently  through  the 
canula  at  the  moment  when  this  is  replaced,  after  they  have 
resisted  all  attempts  at  extraction.  But  all  efforts  may  be  ren- 
dered unavailing ;  the  false  membranes  situated  too  low  or 
being  too  adherent,  remain  firm  and  the  patient  dies  asphyx- 
iated. 


5 so  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

I  close  this  chapter  by  a  few  words  upon  the  care  given  in 
case  of  syncope  or  asphyxia.  One  should  endeavor  to  equal- 
ize the  circulation.  Besides,  for  syncope  he  should  employ  a 
horizontal  position,  mustard  plasters,  slapping  the  face  with  a 
towel  wet  in  cold  water,  etc.;  and  for  asphyxia,  revulsives,  elec- 
triciry  to  the  phrenic  nerve  and  its  branches  to  the  diaphragm, 
and  above  all,  inflation. 

This  last  operation  should  be  practiced  by  means  of  a  tube 
introduced  into  the  canula.  It  is  very  important  to  execute  this 
manoeuvre  with  care, for  by  blowing  with  energy  one  is  liable  to 
produce  pulmonary  emphysema,  and  even  to  rupture  the  lung. 
I  have  seen  a  case  of  double  pneumo-thorax  produced  in  this 
manner,  as  well  as  a  case  of  subcutaneous  emphysema  in  which 
the  air  had  reached  the  neck  and  as  far  as  the  nipple  after 
having  penetrated  the   mediastinum  by  a  pulmonary  fissure. 

The  inflation,  therefore,  should  be  performed  gently,  and  at 
sufficient  intervals  so  as  not  to  fatigue  the  lungs,  and  to  allow 
them  to  react.  It  is  preferably  peformed  through  the  canula  ; 
if  one  is  obliged  to  do  it  through  the  wound,  he  should  be  sure 
that  the  elastic  tube  enters  into  the  trachea,  for  fear  of  pro- 
ducing subcutaneous  emphysema. 

[R.  W.  Parker's  "  trachea  aspirator"  consists  of  a  small  glass  cylinder  to  one  end 
of  which  is  attached  a  flexible  tube,  to  the  other  also  a  tube  and  a  glass  mouthpiece. 
The  glass  cylinder  can  be  half  filled  with  antiseptic  wool,  and  thus  all  risk  of  in- 
fection is  prevented. — Lancet.     Nov.  15,  1884.     p.  897. 

An  aspirator  of  any  form  may  be  attached  to  the  elastic  catheter  or  tube,  and 
made  to  answer  well  for  suction  purposes.] 

Subcutaneous  Emphysema. 

This  infiltration  of  air  into  the  connective  tissue  is  an  acci- 
dent of  the  operation  quite  uncommon.  In  766  cases  I  have 
met  with  it  twenty-two  times.  Millard  and  other  observers 
have  cited  soine  examples  of  it.  It  is  due  in  the  great  major- 
ity of  cases  to  a  faulty  operation,  i.  The  most  frequent  cause 
without  question,  is  the  detachment  (decollement)  of  the  tra- 
chea produced  by  ineffectual  efforts  at  introduction  of  the  can- 
ula.    Should  the  operation  have  been  a  little    tedious,    and, 


ACCIDENTS    OF    TRACHEOTOMY.  55  I 

above  all,  if  the  canula  has  remained  for  some  moments  in  the 
false  passage,  the  air  is  propelled  into  the  loose  connective  tis- 
sue of  this  region  by  inspiration  and  expiration,  and  emphy- 
sema soon  appears.  In  these  cases  it  is  not  rare  to  find,  on 
post  mortein  examination,  an  abscess  of  the  mediastinum,  as 
well  as  emphysema.  2.  K  faulty  incision  of  the  tracJiea,  the 
grave  consequences  of  which  I  have  shown  in  respect  of  the 
introduction  of  the  canula,  is  a  cause  no  less  effectual  of  em- 
physema. 

Latei'al  Incision. — The  parallelism  between  the  incision  in 
the  integuments  and  that  in  the  trachea  is  not  maintained. 

Double  Incision. — The  trachea  may  be  transfixed,  and  that 
in  two  ways.  The  second  incision  is  carried  directly  back- 
wards in  the  median  line,  or  in  one  side  of  the  trachea.  Some- 
times the  canula  passes  through  the  second  opening,  and 
lodges  in  the  connective  tissue  surrounding  the  trachea  or  be- 
tween the  trachea  and  oesophagus.  The  patient  dies  before 
there  is  time  for  the  emphysema  to  occur.  When,  on  the  con- 
trary, the  canula  enters  into  the  trachea,  the  air,  drawn  by  en- 
ergetic efforts,  enters  forcibly  into  the  air-passages.  A  part  of 
the  air  escapes  by  the  second  opening  and  diffuses  itself  into 
the  connective  tissue. 

An  Incision  too  Long. — The  canula  escapes  from  the  trachea 
in  a  short  time,  and  lodges  in  the  connective  tissue,  where  it 
soon  produces  emphysema  by  the  air  which  it  conducts  there, 
whether  it  has  escaped  entirely  from  the  trachea,  or  that  its  in- 
ferior extremity  rests  astride  of  the  inferior  angle  of  the  tra- 
cheal incision.  If  it  escapes  entirely  from  the  trachea  it  forms 
an  incomplete  obstruction  which  impedes  the  escape  of  the  air 
and  facilitates  its  spreading  into  the  connective  tissue.  If  it 
rests  upon  the  inferior  angle  of  the  tracheal  incision,  the  air 
coming  from  without  escapes  in  two  currents,  one  remainino- 
in  the  trachea,  while  the  other  enters  the  connective  tissue.  I 
have  reported  one  case  of  emphysema  caused  by  the  incision 
including  five  rings  and  a  half 

An  Incision  too  Short. — It  sometimes  happens  that  the  tra- 
chea is  simply  punctured,  and  we  then  endeavor  to  enlarge  the 


552  DIPHTHERIA,  CROUP  AND  TRACHEOTOMY. 

opening  by  means  of  a  probe -pointed  bistoury.  From  this  re- 
sults a  certain  delay  during  which  the  little  tracheal  opening, 
deeply  situated  and  often  quite  difficult  to  find,  transmits  the 
air  into  the  surrounding  tissues. 

3.  Too  Short  a  Camda. — The  instrument  should  be  suffi- 
ciently long  for  its  inferior  extremity  to  enter  completely  into 
the  trachea.  Too  short  a  tube  will  certainly  produce  emphy- 
sema. It  is  therefore  necessary  to  select  one  with  reference 
to  the  age  of  the  child.  This  even  is  not  an  infallible  precau- 
tion ;  certain  conditions  may  exist  which  will  render  a  canula 
insufficient,  which,  under  ordinary  circumstances,  would  be 
suitable.     They  are : 

An  Incision  made  too  Low. — If,  instead  of  commencing  the 
incision  immediately  below  the  cricoid,  a  point  where  the  tra- 
chea is  superficial,  and  where  the  vessels  are  less  numerous, 
the  operator  should  neglect  this  precept,  he  is  liable  to  find, 
among  other  accidents,  that  the  canula  which  he  has  selected 
becomes  too  short.  The  production  of  emphysema  is  the  con- 
sequence. 

Tumefaction  of  the  tissues  ixonx  the  most  diverse  causes,  to- 
wit :  abscesses,  erysipelas,  etc.,  may  act  in  the  same  way  even 
when  the  operation  has  been  regularly  done.  The  canula, 
which  at  first  had  the  desired  dimensions,  becomes  too  short  in 
consequence  of  the  lengthening  of  the  track;  then  it  escapes 
from  the  trachea  and  emphysema  results. 

We  can  comprehend  that  emphysema,  when  it  has  been  pro- 
duced, also  increases  the  thickness  of  the  pretracheal  tissues 
and  perpetuates  itself  by  virtue  of  the  same  mechanism. 

Too  great  looseness  of  the  tapes  which  hold  the  canula  acts  in 
the  same  way  by  not  holding  it  down  sufficiently,  and  thus 
exposing  it  to  escape  from  the  trachea. 

The /^r;«  ^/"//zf  <:^w?//rt  has  a  similar  influence.  In  order  to 
spare  the  anterior  wall  of  the  trachea,  the  inferior  extremity  of 
the  tube  has  been  (in  some  instruments)  beveled  off  at  the  ex- 
pense of  the  anterior  aspect.  This  improvement  may,  how- 
ever, have  some  inconveniences.  It  may  happen  that  the  tra- 
cheal incision  being  too  long,  the  superior  part   of  the   bevel 


ACCIDENTS    OF    TRACHEOTOMY.  553 

(slant)  may  be  outside  of  the  trachea,  A  part  of  the  air  which 
circulates  in  the  canula  escapes  by  this  opening  and  diffuses 
itself  into  the  connective  tissue.  Formerly  the  bevel  or  slant 
was  made  too  long;  this  disposition  increased  the  danger. 

4.  Inflation  Practiced  TJuoiigh  the  Wound. — In  certain 
tedious  operations  which  cause  long  delay  in  opening  the  tra- 
chea, as  well  as  operations  performed  in  extremis,  the  patient 
falls  into  a  state  of  suspended  animation  ;  and  immediately  on 
opening  the  trachea  one  hastens  to  apply  inflation  through  the 
wound.  I  have  previously  showed  that  this  manoeuvre  re- 
quires great  care.  I  have  reported,  in  confirmation,  some  cases 
of  emphysema,  and  a  case  of  pneumo-thorax  due  to  this 
cause. 

Commencement. — Emphysema  often  appears  during  the  op- 
eration ;  one  may  observe  it  in  a  few  minutes  or  some  hours 
after.  Several  times  it  was  not  discovered  till  the  next  day,  but 
we  may  suppose  that  its  existence  was  not  noticed  during  the 
first  night. 

In  a  case  reported  by  Millard  it  developed  at  two  different 
times  with  an  hour's  interval ;  the  second  was  probably  caused 
by  the  escape  of  the  canula,  an  escape  which  the  first  puncture 
had  caused. 

Seat. — Sometimes  limited  to  the  region  of  the  wound,  it  often 
extends  to  the  angles  of  the  inferior  maxillary  ;  more  rarely  it 
is  seen  invading  the  face,  the  eyelids  and  the  hairy  scalp.  In 
serious  cases  it  descends  in  front  of  the  sternum  to  spread 
itself  all  over  the  chest,  and  even  to  the  shoulders,  the  arms  and 
the  back.   Finally  in  some  cases  it  becomes  almost  general. 

Symptoms. — I  shall  not  tarry  upon  the  well  known  symp- 
toms of  emphysema.  If  it  occupies  a  large  surface  it  becomes 
the  cause  of  dyspnoea,  and  of  considerable  anxiety.  The  local 
symptoms  which  it  causes  about  the  wound  are  of  much  inter- 
est. The  tissues  sometimes  become  distended  in  such  a  man- 
ner that  the  canula  becomes  too  short.  Occasionally,  it  is  even 
pushed  out  of  the  wound.  As  a  consequence  we  have  to  fear, 
on  the  one  hand,  the  increase  of  emphysema,  and  on  the 
other,  asphyxia,  which  the  difficulty  causes,  and  sometimes  the 
impossibility  of  finding  a  canula  sufficiently  long. 


554  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

The  rapid  death  of  the  patient  often  prevents  the  observa- 
tion of  all  the  phases  of  emphysema ;  but  in  cases  in  which 
death  is  more  gradual,  and  in  those  cases  of  recovery,  we  re- 
cognize that  its  duration  is  in  proportion  to  its  extent  and  to 
the  persistence  of  the  cause.  Thus  it  is  that  one  may  see  it 
disappear  the  next  day  in  some,  the  third  day  in  another,  and 
that  it  still  did  exist  in  one  patient  on  the  ninth  day,  the  time 
of  death. 

Treatme7it. — The  best  treatment  is  the  removal  of  the  cause. 
If  the  canula  is  too  short,  substitute  a  longer  one.  But  the 
tumefaction  may  be  so  great  that  all  the  ordinary  canulas  are 
insufficient.  Millard  reports  a  very  interesting  case  in  which 
emphysema  made  such  progress  that  the  canula,  becoming  too 
short,  one  attempted,  unsuccessfully,  the  introduction  of  the 
gum  tube  and  variously  modified  canulas.  It  was  necessary  to 
hold  the  wound  open,  first  with  the  dilator,  which  it  soon  be- 
came necessary  to  abandon,  and  then  with  a  long  tracheotomy 
forceps ;  the  entire  duration  lasting  several  hours,  till  one  was 
able  to  introduce  a  proper  canula. 

Such  cases,  however  rare  they  may  be,  prove  that  the  prac- 
titioner, in  order  to  avoid  being  surprised  and  having  the  pa- 
tient die  in  his  hands,  will  do  well  to  have  in  his  operating  case 
a  canula  long  enough  to  meet  such  an  emergency.  In  a  case 
in  which  emphysema  appeared  to  be  caused  by  the  bevel  of 
the  canula,  Barthez  had  recourse  to  an  ordinary  canula,  and 
the  infiltration  ceased  immediately. 

After  being  developed,  emphysema,  consecutive  to  tracheot- 
omy, is  amenable  to  the  usual  treatment  of  an  emphysema 
developed  in  the  different  regions  of  the  body,  under  the  in- 
fluences of  various  causes.  In  case  the  gaseous  infiltration  is 
hmited  to  the  vicinity  of  the  wound,  it  is  an  advantage  to 
cover  the  tumor  with  a  coating  of  collodion.  The  compression 
which  results  from  it  is  found  to  be  quite   rationally  indicated. 

Injury  of  the  QEsophagus. 
The  injury  of  the  oesophagus  has  been  regarded  as  an  acci- 


ACCIDENTS    OF    TRACHEOTOMY.  555 

dent  possible  to  tracheotomy.  I  have  never  met  with  it,  neither 
have  the  great  majority  of  observers.  The  flaccidity  of  this 
tube,  and  its  deviation  to  the  left,  shelter  it  almost  absolutely 
from  the  cutting  instrument. 

The  long  list  of  difficulties  and  accidents  of  every  kind 
which  may  complicate  tracheotomy,  is  of  such  a  character  as 
to  intimidate  those  who  are  called  upon  to  perform  this  opera- 
tion. This  is  not  because  it  is  always  of  difficult  execution. 
Often,  on  the  contrary,  it  is  of  extreme  simplicity.  We  may 
assert  that  it  is  either  vciy  easy  or  veyy  difficult.  What  con- 
veys the  thought  better  is  the  uncertainty  in  which  the  opera- 
tor is  nearly  always  placed  at  the  time  of  making  the  first 
stroke  of  the  bistoury.  So  an  operation,  which  might  appear 
to  be  done  without  trouble,  may  offer  the  greatest  difficulties, 
and  vice  versa. 

When  anyone  commences  tracheotomy,  he  should  always  be 
upon  his  guard  and  expect  some  surprise.  Because  of  the 
numerous  variations,  which  the  region  in  which  we  operate 
presents,  tracheotomy  cannot  be  brought  under  invariable  rules 
like  other  operations.  It  requires  of  him  who  would  practice 
it  large  experience  and  a  tested  coolness,  qualities  which  ena- 
ble him  not  to  be  taken  unawares.  However  well  qualified 
one  may  be  in  these  respects,  he  never  feels,  at  the  moment  of 
performing  tracheotomy,  free  from  experiencing  to  a  certain 
degree,  the  apprehension  which  the  unknown  produces. 


SEQUELS  OF  TRACHEOTOMY. 


I 


The  patient  upon  whom  tracheotomy  has  just  been  per- 
formed finds  himself  placed  in  new  conditions.  The  laryngeal 
obstacle  having  been  not  surmounted,  but  rather  set  aside  and 
made  of  no  effect,  croup,  properly  speaking,  no  longer  ex- 
ists. Diphtheria,  as  a  general  disease,  resumes  the  first  place. 
Recovery  will  in  great  measure  depend  upon  the  degree  of  in- 
fection, the  tendency  of  the  false  membranes  to  spread,  and 
the  intervention  of  complications  proper  to  diphtheria.  On  the 
other  hand,  the  patient  finds  himself,  like  all  who  have  under- 
gone an  operation,  exposed  to  the  accidents  which  menace 
wounds  in  general,  and  th(jse  of  the  neck  and  trachea  in  par- 
ticular. The  direct  introduction  of  air  into  the  chest,  without 
its  having  been  previously  warmed  and  moistened  in  the  upper 
passages,  singularly  facilitates  the  development  of  pulmonary 
inflammations,  the  cruel  enemies  of  those  who  have  been  oper- 
ated upon  for  croup,  and  so  much  the  more  formidable,  as 
they  too  often  chipose  their  victims  among  those  who  have  es- 
caped the  dangers  of  infection.  It  was  these  which  harvested 
almost  all  the  patients  before  Trousseau  had,  by  the  invention 
of  the  cravat,  enabled  respiration  to  perceptibly  approach  nor- 
mal conditions.  What  croup  becomes  when  thus  modified  in 
its  natural  course  is  what  I  am  about  to  examine. 

Recovery  may  be  obtained  in  two  ways  :  In  the  first,  the 
patient  having  to  do  with  a  benign  diphtheria,  gradually  im- 
proves when  the  respiratory  difficulty  has  disappeared,  and  re- 
covers of  his  croup,  as  of  a  pharyngitis.  In  the  second,  acci- 
dents or  complications  intervene  which  compromise  the  cure 
more  or  less,  but  which  nevertheless  end  by  subsiding.     These 

(556) 


SEQUELS  OF  TRACHEOTOMY,  557 

symptoms  may  finally  become  worse,  and  a  fatal  issue  should 
then  be  feared. 

Among  these  complications  some  depend  upon  croup  in  so 
far  as  it  is  a  diphtheritic  affection.  These  have  no  special  relation 
to  tracheotomy,  and  I  have  examined  them  already.  Others 
are  the  immediate  consequence  of  the  operation,  being  pro- 
duced during  its  performance  or  continumg  afterwards.  I 
have  already  detailed  them.  A  third  group  includes  those 
which,  while  they  are  the  result  of  the  operation,  do  not  ap- 
pear until  after  a  variable  time.  These  are  the  only  ones 
which  should  find  place  here.  The  history  of  the  sequelae  of 
tracheotomy  may  thus  be  divided  into  two  parts  : 

The  first  will  be  devoted  to  the  evolution  of  croup  after  tra- 
cheotomy when  it  results  in  recovery  without  complications. 

The  second  will  include  the  complications,  but  only  those 
which  are  attributable  to  tracheotomy,  and  the  care  which  they 
require. 

PART  FIRST. 

The  Evolution  of  Uncomplicated  Croup  to  Recovery.  The 
After-Treatment  of  Tracheotomy. 

I  left  the  patient  just  after  the  operation,  replaced  in  bed, 
after  having  swallowed  a  little  warm,  sweetened  wine.  He 
should  be  carefully  tucked  into  his  bed,  which  should  have 
been  previously  warmed.  If  necessary  he  may  be  surrounded 
by  bottles  of  hot  water,  and  even  sinapisms  may  be  ordered 
upon  his  skin,  all  for  the  purpose  of  combatting  the  tendency 
to  chill  which  always  follows  the  operation,  especially  when 
asphyxia  has  progressed  far,  and  when  haemorrhage  has  been 
abundant.  After  a  short  time  the  face  recovers  its  natural 
color,  respiration  becomes  regular,  the  pulse  resumes  its  ful- 
ness, and  the  child  falls  into  a  calm  slumber  which  lasts  for  one 
or  more  hours.  During  this  time  the  dressing  should  be 
watched  so  as  to  be  sure  that  there  is  no  discharge  of  blood. 

Traumatic  Fever. — After  a  few  hours  the  traumatic  fever  ap- 


558  DIPHTHERIA.    CROUP    AND    TRACHEOTO'^IY. 

pears.  The  time  of  its  beginning  varies  with  the  condition  of 
the  patient  at  the  moment  of  operation.  The  more  he  has  un- 
dergone the  influence  of  asphyxia  and  of  blood  poisoning,  the 
more  blood  he  has  lost,  the  more  enfeebled  and  chilled  he  has 
become,  the  later  is  the  appearance  of  reaction.  It  may  su- 
pervene four  hours  after  the  operation  or  not  until  the  day  fol- 
lowing. In  the  opposite  conditions  the  child  reacts  rapidly, 
and  the  fever  appears  without  delay. 

Apart  from  these  considerations,  the  traumatic  fever  which 
follows  tracheotomy  has  no  special  features.  The  pulse 
reaches  140,  or  more  rarely  160  pulsations.  The  temperature 
rises  to  about  39°.  It  often  exceeds  this  degree,  and  remains 
at  about  39.5°  or  39.8°  (103.1°  to  103.6°  F.).  Sometimes  it 
reaches  40°  (104°  F.),  and  I  have  even  seen  it  once  at  40.4° 
(F.  104.7)  without  there  being  reason  to  credit  the  existence 
of  a  pulmonary  inflammation.  It  is  not  the  intensity  of  the 
febrile  movement  which  should  inspire  fears  in  regard  to  it, 
but  its  prolongation.  It  does  not  ordinarily  last  more  than 
one  or  two  days.  When  it  persists  longer,  it  gives  reason  to 
fear  a  complication.  There  are  cases  where  the  reaction  comes 
on  violently,  the  thermometer  reaches  or  exceeds  40°  (104  °F,) 
and  death  supervenes  within  twenty-four  hours.  If,  in  such  a 
case,  the  autopsy  shows  only  unimportant  lesions,  we  are  right 
in  attributing  the  fatal  issue  to  the  intensity  of  the  reaction. 

Expectoration. — In  the  first  moments  following  the  operation 
the  liquids  thrown  out  through  the  canula  contain  a  greater  or 
less  quantity  of  blood,  according  to  the  amount  of  bloody  dis- 
charge which  has  found  its  way  into  the  bronchi.  After  a 
short  time  the  expectoration  changes  its  character,  becoming 
mucous,  thick  and  opaque,  so  as  to  form  large  nummular  sputa, 
somewhat  ragged  and  not  unlike  the  sputa  of  consumptives. 
Sometimes  they  are  so  dense  that  when  the  sponge  pushes 
them  from  the  canula  into  the  spittoon,  they  are  moulded  within 
the  tube  and  assume  the  appearance  of  cylindrical  false  mem- 
branes. It  is  sufficient  to  turn  them  into  a  glass  of  water,  to 
cause  them  to  resume  their  true  character.  The  mucus  be- 
comes diluted  or  remains  transparent,  while  the  false  membrane 


^ 


SEQUELAE  OF  TRACHEOTOMY. 


559 


preserves  its  form  and  its  opacity.  In  other  cases  the  expec- 
toration, while  remaining  mucous,  continues  transparent  and 
more  fluid. 

Such  are  the  characteristics  of  laudable  expectoration.  It 
would  be  of  bad  character  if  it  should  consist  of  a  liquid  which 
is  purulent  or  serous,  grayish,  fetid,  unaerated  and  frothy.  It 
should  always  arouse  anxiety  if  the  patient  operated  upon 
does  not  cough.  It  must  be  concluded  therefrom  that  the 
bronchial  fluids  are  being  imperfectly  discharged  and  that  as- 
phyxia is  gradually  coming  on.  The  absence  of  expectora- 
tion and  dryness  of  the  canula,  are  of  unpleasant  prognosis, 
for  they  indicate  the  existence  of  a  bronchial  inflammation. 
False  membranes,  completely  or  incompletely  detached  from 
the  tracheal  or  bronchial  walls,  and  floating  in  the  air-passages, 
are  often  thrown  through  the  canula  by  coughing. 

The  presence  of  these  products  in  the  metallic  tube,  as  well  as 
their  absence,  is  indicated  by  the  different  noises  made  by  the 
air  passing  through  it.  When  the  expectoration  is  abundant 
the  canula  is  noisy,  it  is  the  seat  of  a  real  gurgle.  When  it  is 
moderate  the  canula  is  quiet  or  gives  rise  to  a  slight  snoring 
sound ;  when  it  is  absent  or  very  slight,  quite  an  acute  whist- 
ling is  made.  If  a  false  membrane  presents  itself  at  the  inner 
end  of  the  canula,  a  characteristic  flapping  sound  is  heard,  ac- 
companied by  rough  and  shrill  noises.  The  respiration  be- 
comes painful,  the  child  coughs  and  makes  energetic  efforts, 
which  usually  bring  about  the  expulsion  of  the  concretion. 

The  canula  should,  therefore,  be  watched  with  great  care. 
When  the  gurgling  noise  is  heard  the  inner  canula  must  be  re- 
moved, cleaned  with  a  sponge  and  its  contents  thrown  into  a 
vessel  of  water,  in  order  to  render  the  inspection  of  the  sputa 
and  false  membranes  easy.  If  we  recognize  by  the  noise 
which  characterizes  the  presence  of  a  false  membrane  below 
the  canula,  that  its  expulsion  is  delayed,  and  that  difficulty  is 
arising  in  the  respiration,  the  child  should  be  made  to  cough, 
and  the  cough  should  be  aided  by  means  of  a  feather,  or  a 
curved  forceps  which  is  introduced  into  the  canula  after  re- 
moving the  inner  one.     If  this  means   does   not  suffice,  a  few 


56o  DIPHTHERIA,  CROUP  AND  TRACHEOTOMY. 

drops  of  tepid  water  should  be  instilled  into  the  canula  by- 
means  of  a  pipette,  every  quarter  of  an  hour.  This  manoeuvre 
has  the  advantage  of  provoking  a  cough  and  of  aiding  in  the 
detachment  of  tracheal  and  bronchial  products.  In  urgent 
cases,  of  great  distress  and  marked  excitement  of  the  patient, 
it  might  be  necessary,  as  I  have  before  indicated,  to  introduce 
the  trachea  forceps  and  even  to  withdraw  the  canula.  When, 
after  an  attack  of  coughing,  a  false  membrane  becomes  en- 
gaged in  the  instrument,  we  are  apprised  of  it  by  an  immediate 
embarrassment  of  respiration.  The  inner  tube  is  then  to  be 
removed  and  cleansed  as  before.  These  important  attentions 
should  be  given  pro  re  nata.  It  is  also  injurious  to  run  to  the 
canula  after  the  manner  of  the  inexperienced,  to  cleanse  it  at 
the  least  noise  which  it  produces.  All  this  is  a  great  detri- 
ment to  the  child  whom  these  unreasonable  manoeuvres  often 
irritate  and  whose  rest  they  disturb.  So,  also,  the  attendant 
should  know  when  it  becomes  noisy  in  such  a  continuous  man- 
ner as  announces  asphyxia.  The  latter  is,  in  fact,  all  the  more 
promptly  produced  and  increased  as  the  respiration  is  effected 
only  through  a  relatively  narrow  channel,  the  calibre  of  which 
may  be  easily  reduced  or  obstructed.  Circumspection  is  still 
more  necessary  when  a  false  membrane  presents  itself  below 
the  canula.  If  we  must,  in  fact,  avoid  uselessly  tormenting  the 
child  by  making  it  cough  and  tickling  the  irachea  for  the  pur- 
pose of  bringing  out  an  imaginary  false  membrane,  we  must, 
on  the  other  hand,  know  how  to  recognize  the  presence  of  this 
foreign  body  and  to  aid  in  its  expulsion.  By  reason  of  these 
difficulties  assistants  attached  to  hospitals  for  children  should, 
when  possible,  be  placed  in  charge  of  these  patients. 

THE  FIRST  CHANGE  OF  THE  CANULA. 

When  twenty-four  hours  have  expired  after  the  operation, 
it  is  well  to  consider  a  change  of  the  canula  already  soiled  by 
blood  and  sputum. 

The  period  which  I   have   assigned   for   the    first    change  of 


SEQUELAE  OF  TRACHEOTOMY.  56 1 

canula  may  perhaps  appear  too  early,  and  I  am  not  ignorant 
that  many  physicians  even  among  those  who  are  famihar  with 
diseases  of  children,  notably  Trousseau,  are  not  willing  to  make 
this  first  dressing  except  at  a  later  period.  I  should  except 
Millard,  who  recommends  the  change  at  the  end  of  twenty- 
four  hours.  Such  is  also  the  opinion  of  Barthez.  By  this  time 
the  track  of  the  canula  is  perfectly  formed,  and  while  its  walls 
do  not  yet  possess  all  the  firmness  that  they  may  acquire,  they 
are,  nevertheless,  firm  enough  to  permit  the  tube  to  pass  easily 
and  without  fear  of  going  astray.  I  have  always  found  this 
practice  easy  of  execution.  It  also  allows  the  inspection  of 
the  wound  and  its  surroundings,  and  giving  them  in  good  sea- 
son the  attention  which  they  require.  Moreover,  it  facilitates 
marvelously  the  expulsion  of  the  false  membranes. 

The  wound  is  in  contact  with  a  foreign  body,  which  irritates 
it  and  against  which  it  reacts.  In  uncomplicated  cases  the  in- 
flammation remains  localized  in  the  track  whose  formation  it 
aids.  But  in  others,  and  unfortunately  the  most  numerous 
cases,  diphtheria,  gangrene,  erysipelas,  and  other  accidents 
arise  to  change  the  character  of  the  wound.  These  complica- 
tions, if  they  are  not  apparent  from  the  first  day,  are,  neverthe- 
less, in  embryo,  and  in  process  of  development  from  that  mo- 
ment. It  is  useful,  therefore,  that  attention  to  cleanliness, 
aided  or  not  by  various  topical  applications  should  be  used  as 
early  as  possible  to  check  the  march  of  the  disease. 

On  the  other  hand,  it  often  occurs  that  a  false  membrane, 
one  or  more,  comes  in  contact  with  the  posterior  orifice  of  the 
canula,  or  into  its  neighborhood,  and  gives  rise  to  symptoms 
which  are  often  disquieting.  It  is  then  that  the  removal  of  the 
canula  often  renders  a  well  marked  set  vice.  Scarcely  is  it  re- 
moved when  a  violent  effort  at  coughing  shoots  the  false  mem- 
brane to  a  distance,  and,  moreover,  if  the  desired  effect  is  not 
obtained,  recource  can  be  had  to  holding  the  wound  agape 
with  the  dilator,  a  proceeding  which  gives  free  access  of  air 
and  provokes  an  energetic  cough,which  often  drives  the  foreign 
body  out.  We  are  still  further  enabled  to  search  for  the  latter 
with  the  forceps,  which  manoeuvre  is   singularly  simplified  by 


562  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

the  absence  of  the  canula.  Should  all  these  means  fail,  then 
let  the  canula  be  returned,  and  a  fresh  attack  of  coughing  is 
produced  which  throws  out  the  false  membrane  in  a  vast  ma- 
jority of  cases. 

The  changing  of  the  canula,  therefore,  at  the  end  of  the  first 
twenty-four  hours,  seems  to  me  to  be  justified.  It  is  well  un- 
derstood that  this  limit  is  not  absolute,  and  that  it  may  be 
shortened  or  lengthened  according  to  circumstances.  If  that 
period  is  about  to  expire,  for  example,  during  the  evening,  it 
would  be  better  to  put  off  the  dressing  till  the  next  morning. 
An  hour  must  also  be  chosen  which  is  remote  from  the  last 
meal.  Without  this  precaution  the  necessary  manipulations 
will  not  fail  to  bring  on  vomiting,  and,  however  small  the 
amount  may  have  been,  alimentation  is  too  necessary  not  to 
enforce  the  avoidance  of  that  accident.  The  necessary  ma- 
terials are  :  a  canula  to  replace  the  first,  a  dilator,  forceps  for 
false  membranes,  quill  feathers,  a  basin  full  of  tepid  water, 
compresses,  dressing  forceps,  olive  oil  or  cold  cream  and  collo- 
dion. The  fatty  substances  and  the  collodion  are  for  the  pur- 
pose of  protecting  the  skin  from  the  liquids  which  discharge 
from  the  wound.  I  advised,  in  1869,  the  substitution  of  collo- 
dion for  the  fatty  materials.  This  agent  applied  about  the 
wound  forms  a  thick  coating  over  the  skin,  a  sort  of  cuirass 
which  protects  it  from  the  liquids  discharging  from  the  wound, 
while  at  the  same  time  it  exercises  a  slight  compression  very 
useful  for  tissues  so  exposed  to  swelling.  When  it  is  neutral, 
this  composition  is  not  at  all  irritating. 

The  canula  ought  to  be  of  the  same  calibre  as  the  first.  If, 
however,  too  small  a  canula  has  been  used  at  the  operation,  it 
should  be  replaced  by  one  of  larger  calibre  at  the  first  dress- 
ing. A  narrow  canula  places  the  respiration  in  unfavorable 
conditions.  The  assistants  may  be  less  numerous  than  for  tra- 
cheotomy. It  is  sufficient  to  have  one  to  hold  the  hands  and 
another  to  hold  the  lower  extremities.  The  child  soon  becomes 
accustomed  to  the  dressing,  and  after  two  or  three  days  the 
surgeon  can  almost  always  do  it  by  himself.  For  the  first  time 
the  patient  may  be  replaced  upon  the   operating  table,   but  it 


SEQUELS  OP'  TRACHEOTOMY.  563 

almost  always  is  sufficient  to  leave  him  upon  his  bed,  which 
should  be  placed  facing  the  light.  At  the  instant  when  the 
canula  is  removed  an  attack  of  coughing  is  produced  which 
throws  out  mucus,  blood,  false  membranes,  etc.  If  no  com- 
plication exists  the  metal  of  the  canula  is  unchanged.  It  may 
be  soiled  with  pus,  blood,  mucus,  etc.,  but  it  ought  not  to  be 
blackened.  Every  alteration  of  the  canula  indicates  a  patho- 
logical condition  of  the  parts  in  contact  with  it.  The  skin 
should  be  carefully  washed  with  a  compress  or  a  sponge 
dipped  in  tepid  water.  The  exploration  of  the  wound  should 
then  be  undertaken.  To  examine  the  deeper  portion  well,  a 
bit  of  charpie  or  wadding  dipped  in  tepid  water  is  passed 
along  the  divided  surfaces.  If  the  wound  is  healthy  its  borders 
and  surroundings  preserve  their  normal  color.  They  are  sup- 
ple, or  there  exists  merely  a  slight  induration  in  the  subcuta- 
neous cellular  tissue,  which  diminishes  neither  the  suppleness 
nor  the  mobility  of  the  skin,  while  the  walls  of  the  wound  are 
partly  separated  so  that  the  air  passes  freely  through. 

In  some  cases  the  walls  and  the  edges  are  softer,  and  the 
canula  is  hardly  removed  when  they  fall  together  into  the 
wound  and  close  it.  The  air  no  longer  penetrates,  and  the 
child  suffocates.  In  this  case  the  dilator  is  speedily  introduced 
into  the  wound,  which  is  held  agape  during  all  the  time  neces- 
essary.  This  manceuvre  gives  a  double  advantage.  It  per- 
mits the  child  to  respire  freely  during  the  whole  time  of  cleans- 
ing, and,  on  the  other  hand,  the  free  entrance  which  it  gives  to 
the  air,  excites  coughing  and  aids  in  the  expulsion  of  tracheal 
or  bronchial  products.  The  walls  of  the  wound  are  rose  col- 
ored, and  present  here  and  there  small  ecchymotic  points 
formed  by  certain  vessels  cut  during  the  operation,  and  often  a 
little  pus  is  beginning  to  exude.  Trousseau,  and  several  phy- 
sicians after  him,  advise  cauterizing  the  wound  with  nitrate  of 
silver  immediately  after  the  operation,  for  the  purpose  of  pre- 
venting diphtheria  in  it.  This  practice  has  been  abandoned, 
for  it  is  powerless  to  prevent  the  wound  from  becoming  dis- 
eased and  may  aid  in  producing  consecutive  inflammation. 
When  the  wound  is  simple  it  is  left  to   itself.     Diphtheria  of 


564  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

the  wound  is  no  more  frequent  for  it.  Attention  to  cleanliness^ 
slightly  stimulating  and  disinfectant  topical  applications,  such 
as  a  I  per  cent,  solution  of  carbolic  or  salicylic  acid,  consti- 
tute the  therapeutics  of  the  wound  which  is  thus  assimilated  to 
simple  wounds. 

While  the  child  is  still  without  the  canula,  the  condition  of 
the  larynx  should  be  ascertained.  For  that  purpose  the  lips  of 
the  wound  are  approximated  with  the  iingers  in  such  a  way  as 
to  prevent  all  access  of  air  through  this  passage.  Another 
method  of  exploring  the  larynx  consists  in  stopping  the  orifice 
of  the  canula  with  the  ball  of  a  finger  before  it  has  been  re- 
moved or  after  it  has  been  replaced.  This  procedure  is  less  trust- 
worthy than  the  former,  for  on  the  one  hand  the  finger  is  often 
too  large  to  lodge  firmly  in  the  orifice  and  seal  it  hermetically, 
and,  on  the  other  hand,  air  may  pass  between  the  walls  of  the 
wound  and  the  canula.  These  are  two  causes  of  error  which  are 
avoided  by  the  first  method. 

If  the  larynx  is  becoming  free,  an  inspiration  more  or  less 
whistling,  according  to  the  degree  of  freedom  from  obstruc- 
tion, is  accomplished  through  the  mouth,  but  if  the  obstacle 
persists  the  child  makes  vain  efforts  to  breathe,  becomes  agi- 
tated, its  face  becomes  cyanotic,  and  the  signs  of  asphyxia  ap- 
pear. In  the  first  case  the  patient  is  left  without  a  canula  so 
long  as  is  possible  without  fatiguing  him.  During  this  time 
the  trachea  and  the  wound  are  at  rest.  The  child  begins  to 
form  the  habit  of  remaining  without  its  canula  and  is  preparing 
for  its  final  removal. 

In  the  second  case  we  hasten  to  re-open  the  wound,  and  re- 
insert the  tube  after  taking  pains  to  cover  the  surrounding 
skin  with  a  coat  of  oil  of  sweet  almonds,  of  cold  cream,  or  bet- 
ter of  collodion.  Finally  the  neck  is  surrounded  with  the 
double  cravat.  After  the  canula  has  been  replaced,  the  con- 
dition of  the  respiration,  of  the  circulation  and  of  the  tempera- 
ture should  be  ascertained. 

The  respiration  should  extend  to  the  whole  chest,  and  be 
without  intermingling  of  rales.  The  number  of  respirations 
varies,  and  should  be  carefully  noted.    There  are  cases,  in  fact, 


SEQUELS  OF  TRACHEOTOMY.  565 

in  which  the  child  is  calm  and  is  making  no  apparent  effort  to 
breathe,  but  on  closer  examination  it  is  perceived  that  each 
respiration  is  very  short  and  that  the  inspirations  are  numerous, 
depth  being  supplemented  by  frequency.  When  there  are 
more  than  forty-eight  inspirations  per  minute,  there  is  almost 
complete  certainty  of  a  pulmonary  complication  or  the  pres- 
ence of  either  loose  or  adherent  pseudo-membranous  products 
in  the  air-passages.  The  origin  of  the  respiratory  trouble 
must  then  be  sought  by  careful  auscultation. 

According  as  the  disease  progresses  toward  recovery,  the 
number  of  respirations  diminishes  little  by  little,  and  soon  re- 
turns to  the  normal.  Care  should  be  taken  to  determine  this 
number  during  the  sleep  of  the  patient,  in  order  to  avoid  the 
acceleration  which  follows  the  slightest  emotion. 

Circulation  follows  the  respiration  exactly.  We  have  seen 
that  in  the  period  directly  following  the  operation,  traumatic 
fever  lights  up  and  is  then  confounded  with  the  fever  which 
pertains  to  the  diphtheritic  affection.  The  febrile  movement 
is  maintained  in  the  neighborhood  of  120  to  140  pulsations,  to 
subside  after  a  few  days  according  to  the  duration  of  the  dis- 
ease. 

The  temperature  does  likewise,  and  subsides  sometimes  sud- 
denly, sometimes  gradually,  while  preserving  a  rise  in  the 
evening. 

Acceleration  of  the  pulse  up  to  160  or  180  pulsations  per 
minute,  and  frequency  of  respiration  beyond  48  respirations 
per  minute,  joined  to  an  elevation  of  temperature  to  about 
39.5°  or  40°  (103°  or  104°  F.)  indicate  with  certainty  that  a 
complication  is  coming  on. 

Final  Removal  of  the  Canula. 

After  the  first  changing  of  the  canula  the  same  dressing  is 
repeated  every  day,  and  the  same  precautions  are  used. 

When  the  air  begins  to  pass  through  the  larynx,  the  trial  is 
made  of  leaving  the  child  a  few  moments  without  the  canula. 
At  this  time,  and  until    complete   recovery,   vigilance   is   more 


566  diphthp:kia,  croup  and  tracheotomy. 

necessary  than  ever.  The  patient  should  not  be  left  a  single 
instant.  Some  one  who  is  able  to  replace  the  canula  should 
be  with  him  constantly.  A  few  moments  are  sufficient 
for  a  child  yet  unused  to  breathing  without  aid  to  be  taken 
with  suffocation  and  to  die,  unless  the  instrument  can  be  im- 
mediately restored  to  its  place.  The  recognized  causes  of  this 
accident  are  :  incomplete  permeability  of  the  larynx,  mucous 
concretions  or  fragments  of  false  membrane  which  come  and 
lodge  in  the  wound  or  in  the  larynx  ;  laxity  of  the  borders  of 
the  wound  which  fall  together  and  close  the  orifice ;  fungous 
granulations  and  the  progress  of  cicatrization  which  contracts 
the  wound,  and  very  often  the  fright  which  the  child  experi- 
ences on  finding  itself  without  the  canula;  it  becomes  agitated, 
coughs,  the  muscles  of  the  larynx  contract  spasmodically,  and 
finally  respiration  ceases.  These  causes  will  be  studied  in  de- 
tail when  1  take  up  the  difficulties  met  with  in  removing  the 
canula. 

As  seon  as  the  patient  appears  fatigued  the  canula  should  be 
replaced.  Little  by  little  its  removal  is  attained,  first  for  a  few 
minutes,  then  for  several  hours,  then  a  whole  day,  and  finally, 
once  for  all.  A  good  sign  of  the  recovery  of  the  larynx  is  the 
passage  of  the  tracheal  sputa  by  way  of  the  mouth. 

During  the  time  that  the  child  remains  without  the  canula, 
care  should  be  taken  to  place  over  the  wound  a  piece  of  fine 
linen  to  receive  the  products  of  secretion,  and  to  support  it  by 
a  woolen  cravat. 

Cautious,  progressive  removal,  based  upon  repeated  explo 
rations  of  the  larynx,  is  condemned  by  Battels,  of  Berlin,  who 
charges  this  practice  with  irritating  the  parts.  He  advises  that 
the  canula  be  finally  removed  from  the  fifth  to  the  eighth  day. 
These  scruples  of  the  Berlin  physician  seem  to  me  exagger- 
ated. When  cautiously  made,  exploration  of  the  larynx  is  of 
no  danger  whatever.  As  to  the  removal  of  the  canula  upon  a 
set  day,  without  any  notion  as  to  the  permeability  of  the  lar- 
ynx, it  would  not  be  justified  by  a  single  consideration.  Here  are 
the  periods  at  which  the  canula  could  be  finally  removed  in  134 
children,  both  in  the  hospital  and  in  my  private  practice  : 


SEQUELiE  OF  TRACHEOTOMY. 


567 


No.  of] 
cases.  I 


At  end  of  ist  day         -        -        -        i 

M 

3i 

"     -       -       -       -    3 

« 

4th 

«        ....         8 

« 

5tli 

"    -       -       -       -   14 

4< 

6th 

"        -       -       -        18 

M 

7  th 

"    -       -       -        -   16 

M 

8th 

"        -       -       -        18 

<t 

9th 

....       7 

« 

loth 

«        -        -        .          8 

l< 

nth 

"    -        -        -        -    4 

« 

12th 

"...          5 

It 

13th 

"     -        -        -        -    6 

" 

14th 

"        -        -                   I 

<l 

15th 

«...        .        -    4 

" 

1 6th 

"        -        -        -          3 

At  end  of  17th  day 

"  1 8th  " 

"  19th  " 

"  20th  " 

"  2ISt  "      ■ 

«  23d  " 

"  24th  "      . 

'*  25th  " 

•'  30th  " 

•'  32d  " 

"  34th  «  ■ 

"  35th  " 

"  4Sth  «    ■ 

"  126th  « 
Total 


No.  of 

cases. 

3 


134 


Dr.  Jacobi  obtained  the  following  results  which   differ   perceptibly    from    the  pre- 
ceding. 


Time. 

17th  day 
1 8th  " 
20th  " 
27th  " 
29th  " 
30th     " 


No.  of 
cases. 


Time. 

35th  " 
42d  « 
44th  " 
46th  " 
54th  « 
Total 


No.  of 
cases. 

2 

-  I 
I 

-  I 
I 

13 


The  shortest  delay  was  17  days. 

Dr.  Max  MuUer  produces  figures  which  seem  truly  surprising: 


568 


DIPHTHERIA.    CROUP    AND    TRACHEOTOMY. 


Time. 
13th  day 
15th  " 
25th  « 
27th  « 
42d  " 
44th  « 
51st  « 
69th     " 


No.  of 

cases. 


Time. 
70th  day 
79th  " 
105th  " 
1 1 2th  " 
1 20th  " 
203d  " 
Total 


No.  of 
cases. 


14 


[See  also  reports  of  Illinois  cases,  page  478. 

The  question  arises,  by  virtue  of  what  causes,  in  so  large  a 
number  of  cases  was  the  removal  of  the  canula  so  long  de- 
layed ?  The  author,  indeed,  informs  us  that  in  one  case  there 
occurred,  nineteen  days  after  tracheotomy,  a  return  of  the  fever 
followed  three  days  afterward  by  the  expectoration  of  a  mem- 
branous tube  coming  from  the  bronchi,  but  that  fact  does  not 
explain  the  general  delay  appertaining  to  the  removal  of  the 
canula. 

An  early  removal  is  the  fortune  of  simple  croups,  dependent 
upon  a  benign  diphtheria  and  not  retarded  by  complications- 
The  late  removal  is  the  result  of  the  complications  which  em- 
barrass the  course  of  the  disease.  These  complications  will  be 
treated  of  later. 

Cicatrization  of  the  Wound. 

In  the  natural  course  of  the  disease,  many  days  elapse  be- 
tween the  removal  of  the  canula  and  the  complete  cicatrization 
of  the  wound.  This  latter  gradually  contracts  and  ends  by  be- 
coming completely  closed  after  a  few  days.  The  regularity 
and  rapidity  of  the  cicatrization  are  constant  in  simple  cases, 
but  the  least  complication,  on  the  contrary,  suffices  to  disturb 
them.  The  examination  of  the  wound  is,  therefore,  valuable 
for   prognosis.     Whenever  cicatrization  occurs  regularly,  the 


SEQUELiE  OF  TRACHEOTOMY.  569 

prognosis  is  favorable.  On  the  contrary  when,  in  the  absence 
of  apparent  cause,  cicatrization  is  arrested  or  retarded,  a  com- 
pHcation  is  to  be  dreaded,  such  as  an  eruptive  fever,  paralysis, 
broncho-pneumonia,  etc.  When  the  wound  is  simple  the  role 
of  the  physician  is  limited  to  directing  the  cicatrization.  For 
a  long  time  custom  prescribed  that  after  the  removal  of  the 
canula,  a  tight  dressing  made  of  strips  of  diachylon  or  court 
plaster  should  be  applied  to  the  wound.  That  procedure  had 
very  serious  inconveniences.  The  patient,  in  fact,  is  far  from 
being  out  of  danger  at  the  time  when  the  canula  is  removed. 
Attacks  of  suffocation  supervene  under  the  influence  of  any 
mental  emotion,  of  sputum  which  is  thrown  out  with  difficulty, 
or  by  the  simple  impression  of  cold  air,  even  when  the  freedom 
of  the  larynx  has  been  fully  ascertained.  When  in  such  cases 
the  wound  is  hermetically  sealed,  the  patient  becomes  as- 
phyxiated and  quickly  dies,  if  there  be  no  one  present  who 
can  render  him  effectual  aid. 

On  account  of  many  accidents  that  practice  has  been  given 
up.  It  is  best  to  leave  the  wound  to  itself,  and  cover  it  with  a 
simple  dressing  or  a  piece  of  fine  linen  which  will  protect  it 
from  the  rubbing  of  the  clothing  while  permitting  it  to  close 
spontaneously.  This  method  allows  all  the  attention  which 
the  wound  may  require,  and  leaves  to  the  air-passages  for  sev- 
eral days  the  help  of  two  orifices  which  supplement  one  an- 
other to  the  advantage  of  both  respiration  and  expectoration. 
Thus  are  avoided  attacks  of  suffocation  caused  by  sputum  re- 
tained in  the  larynx.  During  this  time  that  organ  becomes 
accustomed  to  functional  activity  and  has  become  already  ex- 
ercised when  the  wound  is  finally  closed. 

We  are,  therefore,  limited  to  watching  the  cicatrization  and 
to  stimulating  the  wound,  if  the  progress  be  a  little  slow,  with 
appropriate  topical  apphcations.  The  one  which  has  suc- 
ceeded best  in  my  hands  is  a  i  %  solution  of  carbolic  acid, 
with  which  the  wound  is  touched  several  times  a  day  by  means 
of  a  pair  of  forceps.  If  this  means  does  not  suffice,  a  pencil  of 
nitrate  of  silver  is  to  be  passed  hghtly  over  the  surfaces.  This 
agent  should  also  be  employed   to  repress  the  exuberance  of 


570 


DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 


granulations.  It  is  important  that  the  cicatrix  should  be  reg- 
ular. It  is  situated,  in  fact,  upon  a  prominent  point.  This 
precaution  should  be  taken  into  consideration,  particularly 
with  female  patients. 

In  92  patients  the  cicatrization  of  the  wound  was   completed 
at  the  following  periods : 


Period. 

No.  OF 

CASES. 

Period. 

No.  OF 
CASES. 

At  the  end 

of  7  days 

- 

- 

I 

At  th 

s  end  0 

f  23  days 

4 

« 

8 

" 

- 

- 

I 

" 

24 

« 

-      2 

« 

9 

« 

- 

- 

I 

« 

25 

u 

5 

u 

10 

« 

- 

- 

3 

M 

26 

« 

-    3 

M 

II 

« 

- 

- 

4 

.( 

27 

« 

4 

H 

12 

- 

- 

6 

<( 

29 

« 

-    2 

« 

•3 

(( 

- 

- 

6 

t( 

30 

" 

-         -        -        I 

«< 

•4 

« 

- 

- 

5 

4< 

33 

t' 

-    I 

« 

J5 

« 

- 

- 

6 

l< 

35 

l< 

1 

W 

16 

« 

- 

- 

I 

« 

36 

" 

-    1 

« 

17 

" 

- 

- 

3 

» 

3!^ 

" 

1 

« 

18 

" 

.- 

- 

5 

« 

40 

« 

-     I 

<l 

'9 

" 

- 

- 

3 

« 

43 

M 

1 

M 

20 

« 

- 

- 

7 

M 

80 

« 

-       -        -    I 

U 

21 

'C 

- 

- 

6 

(1 

128 

X 

I 

" 

22 

<( 

- 

- 

5 

Total 

- 

-    92 

Hygiene   of  Patients   Who    Have  Undergone  Operation. 


The  general  treatment,  the  hygiene  of  those  who  have  been 
operated  upon,  is  of  the  greatest  importance.  Every  one 
agrees  that  if  tracheotomy  gives  more  numerous  successes  in 
private  than  in  hospital  practice,  that  difference  should  be  at- 
tributed to  the  superiority  of  the  resources  which  the  former 


SEQUEL.E  OF  TRACHEOTOMY.  5/1 

furnishes  in  care  of  every  kind  :  personal  attention,  food,  reg- 
ularity of  temperature  and  ventilation,  clothing,  etc. 

These  different  departments  of  hygiene  have  all  great  value. 
They  form  a  whole,  no  part  of  which  can  be  subtracted  with 
impunity. 

Alimentation. — The  nourishing  of  those  who  have  been  tra- 
cheotomized  should  be  attended  to  with  great  care.  It  is  an 
indispensable  condition  of  success,  and  yet  this  part  of  the 
treatment  is  one  of  the  most  difficult  to  direct.  The  appetite 
of  the  little  patients  is  often  irregular.  While  satisfactory  dur- 
ing the  first  two  or  three  days,  it  often  diminishes  about  the 
fourth  or  fifth,  and  remains  poor  up  to  the  time  when  the  fever 
subsides  or  the  false  membranes  cease  to  be  formed.  Some- 
times even  the  child  refuses  all  nourishment.  I  have  already 
insisted  upon  the  necessity  of  a  supporting  diet  for  subjects  af- 
fected with  diphtheria.  These  precepts  which  I  need  not  re- 
produce in  detail  find  their  application  more  than  ever,  when 
we  have  to  deal  with  patients  who  have  undergone  tracheot- 
omy. 

Temperature. — From  the  first  the  desired  precautions  have 
been  taken  to  restore  the  warmth  which  is  often  deficient  at 
first.  It  is  also  important,  for  fear  of  thoracic  complications,  to 
keep  the  external  temperature  at  a  proper  average.  The  child 
should  be  protected  from  the  first  by  ample  clothing.  Its  room 
should  be  large,  airy,  and  of  a  southern  exposure  if  possible. 
It  should  always  be  kept  at  a  temperature  of  i8°  to  19°  cen- 
tigrade (65°  to  70°  F.).     See  page  508,  application   of  cravat. 

Aeration. — The  septic  nature  of  diphtheria  makes  of  the  pa- 
tient a  morbid  focus  which  infects  the  patient  himself  and  the 
persons  who  are  about  him.  This  aggravation  in  the  situation 
is  avoided  by  free  ventilation  without  giving  opportunity  for 
chilling.  It  would  be,  therefore,  of  advantage  to  have  an- 
other well  warmed  apartment  beside  the  one  in  which  the 
child  usually  remains,  and  into  which  he  can  be  carried  while 
the  first  is  being  ventilated.  When  this  is  done  and  the  tem- 
perature restored  to  the  proper  point,  the  child  should  be  re- 
turned to  its  former  room.     For  the  same  reasons  the  number 


5/2  DIPHTHERIA,     CROUP    AND    TRACHEOTOMY. 

of  persons  who  remain  in  the  room  should  be  hmited  to   those 
who  are  strictly  necessary. 

Mental  Managejiient. — Calm  and  quiet  are  indispensable  dur- 
ing the  first  few  days.  Immoderate  demonstrations  of  tender- 
ness and  of  feeling  fatigue  the  patient.  All  persons  who  can 
not  avoid  such  exaggerations  should  be  excluded.  The 
mother  even  should  be  no  exception.  The  physician 
should  interpose  his  authority  and  oblige  her  to  look 
at  her  child  from  a  distance  without  showing  herself.  This 
exclusion,  which  at  the  first  glance  may  seem  severe,  is  justified 
by  necessity  first,  and  by  this  consideration  also,  viz.,  that  the 
child  is  much  less  sensitive  to  it  than  is  generally  believed. 
For  a  while  it  may  perhaps  cry  and  ask  for  its  mother  ;  but 
after  a  very  short  time,  if  the  instructions  are  faithfully  ob- 
served, it  will  completely  forget  this  source  of  annoyance.  More- 
over, parents  who  are  too  feeble  or  too  much  overcome  by  the 
affliction,  lose  their  authority  over  the  child  and  become  an 
obstacle  to  its  cure.  At  the  hospital  especially,  where  we 
have  to  deal  with  a  public  usually  less  enlightened  than  that 
in  private  practice,  great  strictness  should  be  exercised  with 
regard  to  the  visits  of  parents.  To  those  who  have  attended 
croup  patients  at  the  hospital,  it  is  evident  that  every  visit  of 
the  parents  is  followed  by  an  aggravation.  The  child  becomes 
agitated,  cries  and  asks  for  its  mother,  the  fever  and  oppression 
are  augmented,  and  the  same  scene  is  repeated  every  day 
without  reckoning  the  dainties  of  bad  quality  with  which 
it  does  not  fail  to  gorge  itself,  to  the  detriment  of  its  appetite 
for  more  nourishing  food.  It  is  not  rare  to  see  certain 
children  take  a  dislike  to  the  hospital,  refuse  to  eat,  grow  pale 
and  thin  and  finally  succumb.  The  lack  of  intelligence  of 
certain  people,  moreover,  surpasses  anything  that  can  be  im- 
agined. I  have  reported  how  the  parents  of  a  child,  operated 
upon  in  the  service  of  Barthez,  kept  ceaselessly  repeating  to 
the  little  patient  that,  "He  would  not  recover,"  and  expressing 
before  him  with  many  demonstrations  the  grief  which  they  felt 
at  his  death.  They  ended  by  removing  him  from  the  hospital 
in  spite  of  Barthez,  for,  they  said,  they   could   not   do  without 


SEQUELiE  OF  TRACHEOTOMY.  573 

their    son,  but    they    allowed    him    to     die    for  lack  of  care. 

Diversion  is  necessary  for  these  patients. 

It  is  important  to  have  the  child  get  up  as  soon  as  possible 
after  the  time  when  the  cessation  of  the  fever,the  disappearance 
of  the  false  membranes  and  the  commencement  of  the  cicatriza- 
tion of  the  wound  are  established;  otherwise  it  grows  pale  and 
gloomy,  appetite  diminishes,  cicatrization  becomes  slow  and 
its  general  condition  which  was  satisfactory  becomes  depraved. 
If,  on  the  contrary,  it  gets  up,  all  this  disappears  as  if  by  en- 
chantment ;  it  becomes  cheerful,  color  reappears  and  the  ap- 
petite returns.  His  sitting  up,  if  well  borne,  should  be  grad- 
ually prolonged,  and  soon  should  be  regulated  by  his  previous 
habits.  After  a  few  days,  governed  by  the  season,  the  child 
can  go  out,  when  comfortably  clothed,  even  before  the  wound 
has  wholly  recovered. 

Treatment  of  Croup  After  Tracheotomy. 

It  is  customary,  when  once  tracheotomy  has  been  done,  to 
leave  the  pharyngo-laryngeal  manifestations  of  diphtheria  to 
themselves.     It  seems,  as  Trousseau  said  : 

"That  we  need  no  longer  worry  about  the  pharyngeal  or  laryngeal  diphtheritic 
manifestations  which  up  to  this  time  called  for  such  vigorous  resistance.  It  seems 
as  if  the  disease  on  its  arrival  at  the  air-passages  had  exhausted  all  its  action,  and  if, 
by  giving  access  of  air  to  the  respiratory  apparatus  by  means  of  tracheotomy,  the  pa- 
tient is  prevented  from  dying,  recovery  will  come  on  ol  itself." 

These  words  are  true  and  stamped  with  the  practical  tact 
which  so  well  characterized  the  illustrious  professor.  Expe- 
rience has  given  grounds  for  them.  Chlorate  of  potassium, 
recommended  by  Isambert,  Andre  and  Millard,  acetate  of  po- 
tassium counselled  by  Labat,  of  Bordeaux  ;  the  balsams,  tried 
by  a  great  number  of  physicians  upon  the  indication  of  Tri- 
deau,  kermes  mineral,  etc.,  have  been  recognized  as  useless. 
It  is  well,  therefore,  to  abstain  from  them,  for  if  they  are  use- 
less they  may  become  pernicious  by  injuring  the  patient's  ap- 
petite and  causing  diarrhoea  and  nausea.  For  the  purpose  of 
preventing  bronchial  inflammations,  and  the  extension  of  the 
diphtheria  to  the  bronchi,  inhalations  have  been  tried  of  the 
vapor  of  pure  water  or   of  water  charged   with  medicaments  • 


574  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

great  jars  filled  with  boiling  water  into  which  emollient  plants 
were  thrown,  were  placed  about  the  patient's  bed.  The  re- 
sults obtained  by  this  method  do  not  appear  to  have  been 
equal  to  the  hopes  which  were  entertained  with  regard  to  it. 
Since  the  invention  of  the  cravat  it  has  become  more  embar- 
rassing than  really  useful  and  is  generally  abandoned.  In  En- 
gland, however,  it  is  much  used,  and  the  patients  are  placed 
under  a  tent  in  which  a  vaporarium  is  placed. — Howse. 


PART  SECOND. 
Complications. 

The  accidents  which  occur  after  tracheotomy  are  of  two 
kinds.  Some  are  of  traumatic  origin  and  are  due  to  the  oper- 
ation; others  are  dependent  upon  the  diphtheritic  infection  and 
are  observed  equally  in  croup  when  not  operated  upon,  and  in 
angina.  The  first  alone  will  be  examined  in  detail.  The  sec- 
ond have  already  been  studied  as  complications  of  diphtheria 
and  of  croup.  Certain  of  them,  viz.,  the  pulmonary  inflamma- 
tions, however,  deserve  mention,  for  the  reason  that  tracheot- 
omy, while  it  is  not  their  sole  or  principal  cause,  nevertheless 
exercises  a  certain  influence  in  their  development.  The  modifi- 
cations which  they  impress  upon  certain  symptoms  of  the 
normal  evolution  of  croup  after  operation,  deserve  to  be 
pointed  out. 

I  will  close  by  indicating  the  causes  which  retard  the  re- 
moval of  the  canula. 

Accidents  of  Traumatic  Origin. 

As  the  incision  involves  the  integuments  and  the  trachea, 
the  complications  have,  consequently,  the  former  or  the  latter 
as  their  theater. 

The  accidents  dependent  upon  the  wound  in  the  soft  parts 
are  haemorrhage,  subcutaneous  emphysema,  abscess  of  the  me- 


sequels:  of  tracheotomy.  575 

diastinum,  phlegmon,  erysipelas,   gangrene  and  diphtheria   of 
the  wound,  to  which  I  shall  add  irregularities  of  cicatrization. 
The  accidents  which  relate   to  the    trachea    are    ulceration, 
stricture,  polypi  and  fistulae. 


CHAPTER  FIRST. 


Accidents  Dependant  Upon  the  Wound  in  the  Soft  Parts. 

H(Bmorrhage  and  subciitaiieous  emphysema  appearing  oftenest 
during  the  operation,  their  history  has  been  given  with  that  of 
the  accidents  of  tracheotomy.  Secondary  haemorrhage  and 
emphysema  which  supervene  after  the  operation,  have  been 
described  in  the  same  place  as  the  former. 

Abscess  of  the  Mediastinum. 

This  accident  of  tracheotomy  is  but  httle  known.  Hardly 
appreciable  by  its  symptoms,  it  is  rarely  recognized  except  at 
the  autopsy.  It  is  found  mentioned  for  the  first  time  in  the 
thesis  of  Millard,  then  in  that  of  Crequy  (1858).  The  follow- 
ing year  Pelletier  de  Chambure  collated  some  observations, 
one  of  which  belonged  to  Barthez  and  two  to  Roger.  I  have 
been  able  to  collect  eleven  cases  which  were  observed  in  the 
service  of  Barthez.  I  shall  notice  also  a  case  belonging  to 
Boeckel,  of  Strasburg,  recorded  in  the  thesis  of  E.  W.  Boeckel. 
The  rarity  of  this  lesion  is,  therefore,  incontestable,  and  per- 
haps the  number  of  cases  has  been  lessened  by  the  difficulty  of 
diagnosis. 

Etiology. — Just  as  subcutaneous  emphysema,  and  a  certain 
number  of  the  complications  which  follow  tracheotomy,  inflam- 
mation of  the  mediastinum  is  often  caused,  not  by  the  opera- 
tion but  by  the  operator.  In  every  case  observed  the  acknowl- 
edged causes  of  the  abscess  were  accidents  in  operation, 
which  have  the  closest  relation  to  those  which  engender  em- 
physema. This  community  of  origin  is  not  surprising  when 
we  bear  in  mind  the  frequent  coincidence  noted  in  these  two 
complications.     Tedious  operations,  numerous  and   incautious 

(576) 


SEQUELiE  OF  TRACHEOTOMY.  577 

attempts  at  introducing  the  canula,  false  passages,  contusion 
and  dissecting  up  of  the  peritracheal  cellular  tissue,  are  the 
usual  causes.  It  is  the  same  with  vicious  incisions  of  the  tra- 
chea, perforation  of  its  posterior  wall,  double  or  lateral  in- 
cisions, all  of  which  serve  to  complicate  the  introduction  of  the 
canula.  These  manoeuvres  result  in  inflammation  or  gangrene 
of  the  wound.  The  inflammation,  developed  in  the  wound 
and  around  the  trachea,  rapidly  reaches  the  cellular  tissue  of 
the  mediastinum. 

This  process  has  been  manifested  in  every  case.  Moreover, 
it  is  interesting  to  observe  that  the  same  diseased  conditions 
of  the  wound  when  it  is  unaccompanied  by  denuding  (detach- 
ment) of  the  trachea,  remain  limited  to  the  wound  in  place  of 
spreading  into  the  mediastinum.  In  one  patient,  whose  history 
I  have  cited  in  detail,  the  abscess  of  the  mediastinum  had  an 
exceptional  origin.  It  seemed  to  result  from  the  action  of  the 
actual  cautery  upon  a  wound  affected  with  gangrene. 

Symptoms. — It  is  usually  impossible  to  assign  special  signs 
to  abscess  of  the  mediastinum,  for  the  autopsy  only  reveals  it. 
In  fact  this  lesion  almost  never  exists  alone,  for  generalized 
diphtheria,  broncho-pneumonia,  or  pneumonia  are  rarely  want- 
ing and  their  symptoms  overshadow  by  far  those  of  the  medi- 
astinal inflammation.  There  are,  however,  autopsies  in  which 
abscess  of  the  mediastinum  has  been  found  alone.  In  such 
cases  it  has  been  remarked  that  after  a  few  days,  at  a  time 
when  the  condition  of  the  patient  seemed  to  be  improving, 
there  came  on  an  intense  fever  accompanied  by  dyspnoea  and 
agitation,  and  which  ended,  without  delay,  in  death.  Pelletier 
de  Chambure  has  well  presented  that  peculiarity.  I  have  been 
able,  in  other  observations,  to  verify  the  accuracy  of  his  state- 
ment. 

The  diagnosis  is  evidently  almost  impossible.  Yet  if  it  can 
be  shown  that  in  a  tracheotomized  subject  the  operation  was 
tedious,  that  false  passages  were  made  and  that  the  wound  has 
been  the  seat  of  phlegmon,  of  erysipelas,  of  gangrene  or  of 
diphtheria  ;  if  then,  after  a  remission  of  several  days,  a  return 
of  the  fever  is  noted,and  of  the  dyspnoea  together  with  accelera- 


5/8  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

tion  of  the  respiration,  we  may  suspect  the  formation  of  an 
abscess  in  the  mediastinum.  Yet  the  rarity  of  this  accident 
should  be  always  kept  in  mind,  and  the  thought  that  the 
chances  are  much  more  numerous  in  favor  of  a  broncho-pneu- 
monia or  some  other  pulmonary  inflammation,  which  compli- 
cations are  much  more  common.  The  chest  of  the  patient 
should,  therefore,  be  carefully  examined  before  pronouncing 
an  opinion,  and  then  even,  when  the  evident  signs  of  respira- 
tory inflammation  fail  to  be  confirmed,  we  should  be  none  the 
less  very  reserved.  It  will  suffice,  in  fact,  to  have  a  slight  ex- 
perience with  patients  with  croup  to  know  how  difficult  and 
uncertain  auscultation  is  with  them.  How  many  pulmonary 
lesions  are  found  on  autopsy  which  the  most  attentive  auscul- 
tation was  not  able  to  discover ! 

Treatment. — The  difficulty  in  diagnosis  usually  prevents  the 
application  of  any  treatment.  But  admitting  that  the  diagno- 
sis has  been  settled,  what  treatment  should  be  employed?  The 
only  rational  means  is  to  trephine  the  sternum ;  but  who  would 
dare  to  employ  such  a  procedure  in  a  patient  operated  upon 
for  croup !  [The  abscess,  when  located,  might  be  opened 
from  the  side  of  the  sternum.] 

Phlegmon  of  the  Wound. 

When  all  the  causes  of  inflammation  to  which  a  wound  of 
tracheotomy  is  subjected  are  examined,  the  wonder  is  that  the 
condition  is  not  constant. 

Under  these  conditions  the  wound  is  rarely  simple,  and  in- 
flammation of  the  walls  and  surrounding  tissue  is  almost  inev- 
itable. In  place  of  furnishing  the  physiological  inflammation 
necessary  to  cicatrization,  the   wound   becomes  phlegmonous. 

The  beginning  occurs  at  the  end  of  the  first  twenty-four 
or  thirty-six  hours.  Up  to  that  time  the  edges  had  remained 
soft,  the  walls  rose-colored,  the  surrounding  tissues  supple  or 
very  slightly  indurated  deep  down,  but  the  skin  has  remained 
movable.  The  walls  grow  pale  while  they  become  indurated 
in  such  a  way  that  the  opening  of  the  wound,  instead  of  being 


SEQUELAE  OF  TRACHEOTOMY.  5/9 

almost  linear,  becomes  gaping  and  elliptical,  while  the  subcu- 
taneous cellular  tissue  swells  around  the  wound  to  an  extent 
which  varies  from  half  a  centimeter  to  several  centimeters. 
However  intense  the  tumefaction  may  be,  the  tapes  and  the 
plate  of  the  canula  leave  their  impress  upon  the  skin,  and  it 
may  be  so  developed  as  to  augment  the  depth  of  the  wound  to 
such  a  degree  that  the  canula  may  become  too  short,  which 
exposes  the  patient  to  emphysema  and  to  suffocation.  It  fur- 
ther happens  that  in  consequence  of  the  tumefaction  the  skin 
becomes  too  tight,  and  no  longer  completely  covers  the  sub- 
cutaneous cellular  tissue  which  it  leaves  uncovered  in  the  form 
of  a  border  on  a  level  with  the  edges  and  the  angles  of  the 
wound.  That  cellular  margin  often  serves  as  a  starting  point 
for  a  new  complication,  viz.,  erysipelas  or  diphtheria  of  the 
wound.  The  skin  becomes  tense,  immovable  and  red.  This 
discoloration  which  occupies  a  quite  large  zone  or  forms  simply 
a  narrow  border  about  the  wound,  shades  off  insensibly  and 
becomes  confounded  with  that  of  the  healthy  skin. 

Quite  frequently  the  inflamed  skin  becomes  covered  with 
little  vesicles  like  those  of  miliary  fever,  and  filled  with  a 
white  opaline  liquid.  Sometimes  few  in  number  but  often 
very  numerous,  they  may  be  situated  above  the  wound  but 
oftener  below  it,  at  that  portion  which  is  exposed  to  contact 
with  the  liquids  which  flow  out  of  the  canula  ;  it  is  not  rare  to 
see  them  forming  a  sort  of  crescent  which  follows  the  contour 
of  the  shield  of  court  plaster.  They  are  quite  confluent  at 
this  point,  but  become  more  scattered  above  and  below.  After 
they  have  matured  they  dry  up  and  the  epidermis  forms  again 
beneath.  In  less  fortunate  cases,  which  are  quite  common, 
the  floor  of  these  vesicles  is  formed  by  a  minute  false  mem- 
brane which  often  enlarges  and,  by  uniting  with  those  of  the 
neighboring  vesicles,  forms  patches  of  cutaneous  diphtheria. 
This  form  of  inflammation  of  the  wound  rarely  ends  in  sup- 
puration. In  five  cases  only  have  I  seen  abscesses  formed.  Two 
of  them  were  situated  above  the  wound.  The  third  was  dis- 
covered at  the  autopsy,  and  was  found  between  the  os  hyoides 
and   the    thyroid    cartilage  on  the  one  hand,   and  the  thyro- 


580  DIPHTHERIA.    CROUP    AND    TRACHEOTOMY. 

hyoid  membrane  and  the  sterno-  and  thyro-hyoid  muscles  on 
the  other,  a  fourth  had  formed  below  the  inferior  angle  of  the 
wound.  With  the  last  patient  quite  a  large  number  of  ab- 
scesses were  met  with  upon  the  neck  and  face. 

Termination  by  nlceration  is  more  common,  by  reason  of  the 
general  alteration  of  nutrition  in  diphtheria.  The  process  is 
usually  limited  to  the  angles  and  edges  of  the  wound,  espec- 
ially at  its  lower  half  Sometimes  it  extends  to  the  surround- 
ing skin  where  it  produces  quite  extensive  losses  of  tissue. 
The  ulcerated  parts  usually  present  a  rose-colored  floor,  rarely 
gray,  and  its  edges  are  regular  and  slightly  salient.  The  metal 
of  the  canula  is  unaltered.  When  the  patient  is  to  recover, 
these  disorders,  after  lasting  for  some  days,  subside,  the  red- 
ness diminishes,  the  induration  undergoes  resolution,  the  ulcer- 
ated parts  are  repaired,  the  wound  becomes  smaller  and  the 
work  of  cicatrization  recommences.  The  inflammatory  com- 
plication is  never  very  severe  of  itself.  It  is  almost  inevitable 
and  recovers  perfectly  when  no  other  accident  occurs. 

Treatmeiit. — An  inflammation  of  moderate  intensity  demands 
more  than  ever,  attention  to  cleanliness.  The  skin  about  the 
wound  should  be  frequently  cleansed  and  coated  with  some 
fatty  substance,  such  as  oil  of  sweet  almonds  or  cold  cream. 
If  the  tumefaction  is  somewhat  considerable,  applications  of 
collodion  will  be  of  great  service.  If  the  inflammation  is  more 
extended,  recourse  should  be  at  once  had  to  the  same  care, 
and  every  topical  application  containing  any  irritant  substance 
should  be  rejected.  Then,  as  the  canula  is  the  most  efficient- 
agent  in  producing  the  irritation,  the  attempt  should  be  made 
to  relieve  the  child  of  it  as  soon  as  possible.  The  induration 
of  the  borders  of  the  wound,  by  making  an  almost  rigid  duct 
of  the  passage,  favors  the  introduction  of  the  air  and  facilitates 
leaving  out  the  canula.  While  he  is  in  this  situation,  he  should 
be  very  closely  watched,  for,  during  the  first  few  days,  he  tol- 
erates it  with  difficulty  ;  the  respiration  becomes  easily  ob- 
structed and  suffocation  comes  on  rapidly.  The  canula  should 
be  replaced  at  the  end  of  half  an  hour,  a  quarter  of  an  hour,  or 
less.  If  the  swelling  of  the  cellular  tissue  is  considerable,  a 
longer  canula  than  the  first  may  be  needed. 


SEQUELiE  OF  TRACHEOTOMY,  58  I 

The  tendency  to  ulceration  should  be  combated  with  the 
solution  of  carbolic  acid,  and  if  necessary,  by  nitrate  of  silver. 

Erysipelas  of  the  Wound. 

Erysipelas  recognizes  the  same  apparent  causes  as  simple 
phlegmasia.  As  to  the  essential  cause  of  that  inflammation 
we  cannot  penetrate  it  in  the  case  of  tracheotomy  more  than 
in  any  other.  I  have  seen  tracheotomized  children  affected 
with  erysipelas  of  the  wound,  when  there  was  not  a  case  of 
that  disease  in  the  hospital.  Its  almost  constant  coincidence 
with  gangrene  of  the  wound  should,  however,  be  noted.  This 
complication  is  much  the  less  frequent,  and  several  years  may 
go  by  without  its  being  met  with.  I  have  already  recorded 
thirteen  cases,  and  another  has  been  cited  by  Blanchetiere.  It 
begins  most  frequently  at  the  end  of  one  or  two  days,  but  in 
the  instance  of  Blanchetiere's  it  was  postponed  till  the  fifth 
day. 

Prodromata  are  almost  always  wanting ;  the  general  symp- 
toms disappear  in  the  group  of  symptoms  which  characterizes 
croup.  Blanchetiere's  patient  had  a  very  high  fever  during  the 
entire  period  following  the  operation.  The  temperature  re- 
mained constantly  above  40°  (104°  F.)  and  rose  to  40.1°,  while 
the  frequency  of  the  pulse  corresponded  with  the  elevation  of 
temperature. 

The  local  symptoms  are,  at  first,  the  same  which  character- 
ize simple  phlegmasia,  viz.,  induration  of  the  tissues,  pallor  of 
the  wound,  which  becomes  gaping,  a  red  zone  around  its  bor- 
der, and  sometimes  little  phlyctenules  full  of  yellow  fluid  ap- 
pearing upon  its  borders.  The  next  day  the  redness  has  ex- 
tended and  is  bounded  by  the  hard,  salient,  fimbriated  border 
which  characterizes  erysipelas.  The  phlyctenules  are  repro- 
duced and  increase  in  volume,  while  the  skin  is  hard,  painful 
and  tense.  The  exanthem  may  remain  limited  to  the  neigh- 
borhood of  the  wound,  but  in  certain  cases  it  assumes  the  ser- 
piginous form  and  overruns  the  whole  body. 

The  surrounding  parts  are  usually  healthy.     It  is   not  rare, 


5^2  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

however,  to  observe  around  the  wound,  before  the  appear- 
ance of  the  erysipelatous  patches,  a  soft  swelHng  which  has  a 
great  tendency  to  spread  to  a  distance.  It  succeeds  very  often 
in  reaching  the  jaws  and  the  sternum,  when  the  projection  of 
the  angle  of  the  jaw  is  obliterated,  the  glands  become  indu- 
rated and  painful,  as  in  the  case  of  pharyngitis.  The  sternal 
fourchette  disappears,  while  the  presternal  cellular  tissue  in- 
creases in  volume,  and  that  of  the  chest  and  of  the  back  may 
be  invaded  in  its  turn.  The  tumefaction  of  the  cellular  tissue 
is  soft  and  distinguished  from  that  of  emphysema  by  the  ab- 
sence of  crepitation.  It  is  painless  and  forms,  in  some  sort, 
the  advance  guard  of  the  erysipelatous  swelling  proper  which  is 
characterized  by  redness,  hard  swelling,  pain,  phyctenules,  etc. 
If  erysipelas  alone  prevails,  the  walls  of  the  wound  are  pale 
and  suppurate  but  little,  and  the  canula  is  clean;  but  if  to  the 
erysipelas  is  added  gangrene  of  the  wound,  which  is  very  com- 
mon, the  wound  alters  its  character  and  the  canula  becomes 
blackened.  The  course  of  the  erysipelas  offers  nothing  worthy 
of  special  mention. 

The  prognosis  is  unfavorable,  and  patients  who  undergo  this 
complication  rarely  escape  death.  In  thirteen  I  saw  but  three 
recover.  The  gravity,  however,  does  not  always  correspond 
with  the  extent  of  the  surface  invaded.  I  have  noticed  recov- 
ery in  a  patient  where  the  erysipelas  had  overrun  the  whole 
body ;  and,  per  contra,  cases  of  quite  limited  erysipelas  have 
resulted  in  death. 

We  find  a  satisfactory  explanation  in  that  general  patholog- 
ical law  according  to  which  malignant  exanthems  are  often 
distinguished  by  the  slight  extent  of  their  cutaneous  manifes- 
tations. 

Treatment. — Attention  to  cleanliness,  applications  of  starch, 
fatty  substances  or  collodion,  together  with  removals  of  the 
canula  as  frequent  and  as  prolonged  as  possible,  are  the  only 
measures  to  be  recommended. 

Gangrene  of  the  Wound 

I  have  drawn  attention  to  the  frequency  of  this  accident  and 


i 


SEQUELiE  OF  TRACHEOTOMY.  583 

have  shown  that  it  is  often  confounded  with  diphtheria  of  the 
wound.  In  fact,  gangrene  of  the  wound  is  not  only  that 
which  is  characterized  by  phlyctenules  and  by  large  black  es- 
chars, but  it  also  presents  itself  under  the  form  of  thin,  gray 
patches  which  have  a  certain  resemblance  to  the  pseudo-mem- 
branous exudate.  It  is  the  most  frequent  of  the  complications 
which  follow  the  operation.  It  is  rare  for  a  tracheotomy  wound 
not  to  be  affected  to  a  certain  degree  with  gangrene,  varying 
from  the  mortification  of  a  few  isolated  points  to  an  extensive 
destruction  of  the  coverings  of  the  neck. 
Gangrene  of  the  wound  is  of  two  varieties  : 

1.  Superficial  gangrene  if  the  internal  surface  of  the  wound. 
— A  frequent,  benign  form  due  almost  wholly  to  the  pressure 
of  the  canula  upon  the  already  inflamed  tissue. 

2.  Extensive  and  deep  gangtene  of  the  track  of  the  wound 
zuith  or  without  extension  to  the  skin,  enlarging  beyond  measure 
the  opening  and  the  track  of  the  wound,  and  caused  at  once 
by  diphtheritic  infection  and  by  compression  ;  a  grave  and 
rarer  form. 

The  causes  are  at  once  local  and  general.  The  local  cause 
is  the  presence  of  the  canula  which  acts  in  a  manner  easy  to 
understand.  The  divided  tissues  contract  by  virtue  of  their  elas- 
ticity, against  the  canula,  a  rigid  body  which  constantly  tends 
to  separate  them.  The  best  demonstration  of  this  mechanism 
is  given  by  the  rapidity  with  which  haemorrhages  produced  by 
the  operation  are  arrested  as  soon  as  the  canula  is  put  in 
place. 

To  this  purely  dynamic  cause  are  added  general  conditions, 
i.  e.,  the  diphtheritic  infection  which  alters  the  economy  to  a 
great  degree,  and  diminishes  the  activity  of  nutrition.  This 
influence  is  of  great  weight.  Vigorous  subjects,  with  whom 
the  vitality  of  the  tissue  is  energetic,  are  less  subject  to  spread- 
ing gangrene  than  children  who  are  thin,  pale  and  scrofulous, 
or  deteriorated  by  bad  hygiene.  It  is  also  among  those  who 
show  the  most  manifest  signs  of  septicaemia  that  the  cases  of 
deep  gangrene  are  met  with. 

These  two  classes  of  causes  are  reciprocally  supplementary. 


584  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

while  singly  they  are  less  active.  Those  who  have  undergone 
tracheotomy  for  a  non-infectious  laryngeal  lesion,  oedema  of 
the  glottis,  for  example,  wear  their  canula  for  a  very  long 
time,  often  for  years,  without  experiencing  the  least  gangren- 
ous alteration  of  the  wound.  The  same  fact  occurs  even 
among  those  who  are  operated  on  for  croup,  when,  after  the 
fever  has  subsided,  and  the  diphtheritic  affection  has  recov- 
ered, any  cause  whatever  obliges  them  to  retain  the  canula 
after  the  ordinary  time.  I  observed  a  child  of  5  years,  who, 
after  tracheotomy  was  obliged  to  retain  the  canula  for  126 
days  on  account  of  a  spasm  of  the  glottis  which  arrested  res- 
piration at  every  attempt  at  removal,  and  throughout  this  long 
space  of  time  the  wound  remained  healthy.  In  superficial 
gangrene  the  dynamic  element  preponderates,  while  the  gen- 
eral element  overbalances  in  deep  and  diffuse  gangrene. 

Superficial  gangrene  begins  about  the  third  or  fourth  day 
after  the  operation.  At  this  period  the  change  is  difficult  to 
recognize,  for  it  is  situated  upon  the  walls  of  the  wound  which 
are  already  colored  white  or  yellowish  gray  by  the  pus  which 
they  discharge,  a  tint  which  is  confounded  with  those  of  the 
mortified  part.  Moreover,  the  beginning  passes  unnoticed,  at 
least  if  we  are  not  guided  by  one  sign  which  is  never  wanting. 
I  refer  to  the  alterations  on  the  surface  of  the  canula.  It  does 
not  apply,  however,  except  to  silver  canulas. 

When  the  wound  is  healthy  or  simply  inflamed,  the  metal 
remains  white  and  polished.  It  may  be  soiled  with  blood,  pus 
or  some  other  substance,  but  washing  restores   its   brightness. 

The  chemical  reaction  which  takes  place  on  this  occasion 
appears  peculiar  to  gangrene.  The  contact  of  the  air  is  not 
sufficient  to  impress  upon  the  pus  such  modifications  as  will 
enable  it  to  blacken  silver.  Aside  from  the  gangrenous  con- 
dition, the  canula  is  never  altered  even  when  it  is  worn  for 
several  months.  The  disengagement  of  sulphurated  hydrogen 
by  organic  bodies  is  one  of  the  phenomena  of  their  putrefac- 
tion, and  in  the  case  of  gangrene  it  bears  witness  to  the  inten- 
sity of  the  infection,  and  of  the  disturbance  which  it  brings 
about  in  the  vitality  of  the  tissues.     From  the  time   when  the 


SEQUELS  OF  TRACHEOTOMY.  585 

slightest  mortified  point  is  found  upon  the  walls  of  the  wound, 
a  black  stain  is  produced  upon  the  corresponding  portion  of 
the  canula.  This  extends  with  the  gangrene,  and  its  daily 
variations  indicate  the  progress  of  the  disorganization.  At 
the  beginning,  if  the  gangrene  is  at  first  limited,  a  small,  dark 
stain  is  formed  on  the  portion  of  the  cylinder  which  lies  near 
the  flange.  This  stain  is  slight,  iridescent  rather  than  black, 
and  the  silver  still  preserves  its  brightness.  In  proportion  as 
gangrene  progresses,  the  stain  extends,  becoming  of  a  deep 
black  and  altering  the  polish  of  the  metal.  It  may  thus  spread 
over  the  upper  half  or  two  thirds  of  the  canula.  It  rarely 
passes  this  limit,  and  the  lower  half  remains  unchanged,  at 
least  unless  an  ulceration  of  the  trachea  supervenes,  caused 
by  the  friction  of  the  lower  end  of  the  canula,  in  which  case 
that  extremity  becomes  blackened  in  its  turn.  It  is  very  rare, 
however,  to  see  the  canula  entirely  black,  for  there  always  re- 
mains an  unchanged  zone  between  those  which  are  altered. 
Deep  and  generalized  gangrene  forms  an  exception  to  this 
rule.  Thus  the  site  and  extent  of  the  eschar  will  be  revealed 
with  precision  by  the  alteration  of  the  metal  of  the  canula. 
When  the  canula  has  been  found  to  be  blackened,  the  wound 
should  be  carefully  examined,  after  first  washing  it  by  passing 
a  bit  of  charpie  or  moistened  wadding  over  its  walls. 

When  the  surfaces  have  been  thoroughly  cleansed,  one  or 
more  patches  of  variable  extent  are  perceived.  Sometimes 
they  are  only  the  size  of  millet  seeds,  slightly  salient  and  of  a 
gray  or  yellowish  color.  They  are  also  met  with  either  upon 
the  edges  of  the  wound  or  upon  its  angles,  but  they  choose  as 
their  place  of  election  the  angles,  and  especially  the  inferior 
angle  ;  at  a  distance  they  show  a  very  great  resemblance  to 
false  membranes.  Sometimes  the  tract  is  carpeted  with  a  pulpy, 
grayish  and  adherent  coating.  Fragments  of  these  patches, 
torn  off  with  a  pair  of  forceps  and  placed  under  the  microscope 
reveal  their  origin  by  their  structure  which  includes  elements 
of  striated  and  muscular  tissue. 

Superficial  gangrene  does  not  extend  far.  The  canula  re- 
mains slightly  blackened.       The  exudation   which   arises  from 


586  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

the  surface  of  the  wound  is  sero-purulent  or  serous,  and  of  a 
yellowish  gray  color.  The  odor  is  often  faint,  but  sometimes 
really  gangrenous.  The  period  of  elimination  comes  on 
promptly,  the  eschars  become  detached,  the  track  of  the  wound 
resumes  the  appearance  of  a  simple  wound,  and  as  the  loss  of 
substance  has  been  slight,  the  configuration  of  the  parts  is  but 
little  modified  unless  the  edges  were  themselves  affected,  in 
which  case  the  orifice  becomes  irregular. 

Deep  Gangrene. — But  often  the  gangrene  extends  and  the 
wound  becomes  covered  little  by  little  with  a  uniform,  thick, 
adherent  layer  of  a  yellowish  brown  color,  which  reaches  be- 
yond its  circumference  at  one  or  more  points.  At  the  same 
time  the  walls  are  bloody  and  a  grayish  or  reddish,  fetid,  san- 
ious  pus  oozes  out.  The  edges  become  indurated  and  irregu- 
lar. The  surrounding, tissues  are  swollen  and  hard,  the  skin 
is  no  longer  movable  upon  the  connective  tissue.  It  assumes 
a  livid  tint  and  sometimes  the  epidermis  is  lifted  up  by 
phlyctenules  filled  with  a  reddish  serous  fluid.  When  these 
phlyctenules  break  they  reveal  the  derma  already  disorganized 
in  part  and  taking  on  the  aspect  of  a  brown  eschar.  Little  by 
little  the  lesion  extends  and  may  attain  a  distance  of  several 
centimeters  from  the  wound  in  one  direction  or  in  another  or 
in  all  directions  at  once.  It  penetrates  into  the  trachea  and 
attacks  the  mucous  membrane  and  the  cartilages ;  sometimes 
it  even  invades  the  mucous  membrane  and  the  cartilages  of  the 
larynx.  In  very  rare  cases  it  extends  as  far  as  the  parenchyma 
of  the  lungs.  The  patient's  breath  exhales  an  odor  peculiar 
to  gangrene.  The  canula  becomes  blackened  over  its  whole 
surface. 

Such  extensive  disorganization  is  not  common,  either  be- 
cause it  limits  itself  or  because  the  patient  dies  before,  as  unfor- 
tunately, frequently  is  the  case,  whenever  lesions  attain  a  cer- 
tain depth. 

The  period  of  elimination  is  marked  by  losses  of  substance 
which  are  often  considerable.  The  wound  is  filled  with  frag- 
ments of  eschars,  with  shreds  of  mortified  cellular  or  muscular 
tissue,  and  sometimes  with   cartilaginous   debris   coming    from 


SEQUELAE  OF  TRACHEOTOMY.  587 

the  rings  of  the  trachea,  all  bathed  in  a  brown  and  fetid  serous 
ichor.  There  has  even  been  observed  a  very  extensive  des 
truction  of  the  thyroid  and  cricoid  cartilages  as  well  as  a  com- 
plete elimination  of  several  rings  of  the  trachea.  If  the  patient 
resists,  this  stage  follows  its  habitual  course :  the  eschars  are 
thrown  off,  suppuration  becomes  normal  again,  and  we  find 
ourselves  in  the  presence  of  a  simple  wound.  It  is  evident 
that  the  opening  is  enlarged  in  consequence  of  the  destruction 
of  a  portion  of  its  walls,  and  what  remains  of  them  is  irregular, 
and  anfractuous.  The  edges  have  become  sinuous  and  are  re- 
moved from  their  primitive  situation.  The  denuded  surfaces 
become  again  covered  with  a  layer  of  granulations  secreting  a 
healthy  pus. 

Cicatrization  is  in  its  turn  resumed  and  follows  its  regular 
course,  unless  other  obstacles  arise  to  prevent  it.  It  is  marked 
by  contraction  followed  by  vicious  cicatrices  which  are  the 
more  marked  in  proportion  as  the  loss  of  substance  has  been 
more  considerable.  Strictures  of  the  trachea  and  of  the  larynx 
are  the  consequences  of  these  accidents. 

The  general  symptoms  present  nothing  peculiar.  As  the 
gangrene  is  the  expression  of  a  grave  general  condition,  its 
symptoms  are  confounded  with  those  which  correspond  to  that 
condition,  viz  :  high  fever,  anorexia,  agitation,  etc. 

At  the  moment  when  the  stage  of  elimination  arrives  if 
there  be  no  other  complication,  the  general  condition  improves. 
It  would  be  nearer  correct,  in  certain  cases,to  reverse  the  prop- 
osition, and  to  say  that  the  gangrene  is  arrested  when  the 
general  condition  of  the  patient  becomes  more  favorable. 

The  prognosis  always  presents  a  certain  gravity  from  this 
fact  alone,  that  the  gangrene  is  the  index  of  an  advanced  in- 
fection. The  absence  of  gangrene  is  a  very  favorable  sign. 
The  gravity  varies  with  the  extent  of  the  lesions.  Partial, 
superficial  gangrenes  are  the  least  severe  for  they  show  a  low 
degree  of  blood  poisoning.  Those  which  are  extensive  and 
deep  are,  on  the  contrary,  very  formidable,  while  the  deformi- 
ties of  the  cicatrix,  and  especially  the  laryngeal  and  tracheal 
strictures  which  follow  them,  add  still   further  to   the  dangers 


5^8  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

of  this  accident  by  causing  grave  inconvenience  to  patients  who 
have  survived  the  acute  stage. 

Diagnosis. — Ulceration  and  diphtheria  of  the  wound  may  be 
confounded  with  gangrene. 

When  the  wound  is  inflamed  and  becomes  converted  into  an 
irregular  ulceration,  limited  to  the  track  or  not,  when  its  sur- 
face becomes  grayish  and  secretes  a  serous  pus,  it  assumes  an 
aspect  which  is  not  unlike  that  of  gangrene,  especially  in  the 
deeper  parts.  But  the  difficulty  disappears  if  care  be  taken  to 
wash  the  wound  thoroughly  with  a  moistened  hair-pencil,  for 
the  absence  of  any  eschar  is  then  recognized.  The  canula  is 
unaltered  in  the  majority  of  cases. 

But  it  is  not  so  easy  to  distinguish  gangrene  from  diphtheria. 
When  the  false  membrane  is  situated  externally,  around  the 
edges,  and  in  the  neighborhood  of  the  wound,  the  diagnosis  is 
more  easy,  for  the  well-known  differential  features  of  gangrene 
and  of  cutaneous  diphtheria  are  amply  sufficient.  But  the 
difficulty  becomes  real  in  cases  where  the  lesion  appears  upon 
the  walls  of  the  wound  at  a  certain  depth.  Under  these  cir- 
cumstances the  false  membrane  and  the  eschar  present  some 
resemblance  which  renders  the  inquiry  very  delicate  and  has, 
many  a  time,  led  uninformed  observers  into  error.  Thence 
comes  the  exaggerated  predominance  for  a  long  time  assigned 
to  diphtheria  of  the  wound.  Nevertheless,  a  diagnosis  may  be 
arrived  at  by  means  of  the  following  features  : 

In  gangrene  the  swelling  of  the  tissues  is  more  intense  than 
in  diphtheria.  They  are  also  of  firmer  consistence,  and  the 
skin  is  no  longer  movable  upon  the  sub-cutaneous  tissues. 
However  small  in  extent  the  gangrene  may  be,  the  character- 
istic fetid  odor  of  the  wound  is  striking.  A  gray  or  brown 
sero-purulent  discharge  oozes  out  or  is  brought  out  by  the 
hair  pencil.  In  diphtheria  the  odor  is  entirely  different.  The 
false  membrane  is  smooth,  thin  around  its  edges,  adherent,  ir- 
regular and  usually  white,  though  its  transparency  sometimes 
makes  it  appear  slightly  brown  when  it  rests  on  the  sanguin- 
eous base.  Fragments  can,  moreover,  be  torn  off  with  forceps, 
which  present  very  clearly  all  the  features  of  diphtheritic  false 


SEQUELS  OF  TRACHEOTOMY.  589 

membrane.  The  eschar  is  rugose,  unpolished,  more  salient 
than  the  false  membrane,  and  with  ragged  edges  ;  while  its 
color  which  at  first  is  yellow  verging  toward  brown,  afterwards 
assumes  a  dark  brown  tint.  It  can  also  be  torn  off  in  frag- 
ments by  means  of  a  pair  of  forceps ;  but  it  brings  with  it 
pieces  of  mortified  connective  tissue. 

The  canula  which  in  gangrene  is  profoundly  blackened  re- 
mains intact  when  diphtheria  exists  alone.  In  cases  where  the 
eschars  are  small  and  deep  down,  or  the  peculiar  odor  and 
color  of  the  discharge  are  lacking,  the  black  tint  of  the  canula 
is  often  sufficient  to  diagnosticate  gangrene,  for  if  not  path- 
ognomonic it  at  least  belongs  almost  exclusively  to  that  le- 
sion. In  doubtful  cases  the  microscope  gives  the  final  de- 
cision. 

The  course  and  duration  may  also  furnish  elements  in  the 
diagnosis,  for,  if  diphtheria  and  gangrene  appear  at  the  same 
time,  the  duration  of  the  former  is  less  than  that  of  the  latter; 
on  the  other  hand  gangrene  does  not  reappear  when  it  has  once 
disappeared,  while  diphtheria,  on  the  contrary,  may  give  rise 
to  several  attacks,  and  it  is  not,  like  gangrene,  confined  to  the 
beginning.  So  then,  when  one  of  these  comphcations  appears 
at  an  advanced  stage  of  the  disease,  whether  the  wound  have 
been  healthy  up  to  that  time,  or  whether  it  have  been  diseased, 
all  the  probabiHties  are  in  favor  of  diphtheria.  In  those  quite 
frequent  cases  where  gangrene  is  associated  with  diphtheria, 
the  diagnosis  becomes  more  difficult,  and  often,  when  the  le- 
sions are  situated  in  the  deeper  portions  of  the  wound  it  is  not 
easy  to  determine  the  part  which  is  referable  to  each.  The 
indisputable  presence  of  false  membranes  upon  the  edges,  or 
upon  the  circumference  of  the  wound,  is  at  once  a  strong  pre- 
sumption in  favor  of  diphtheria,  and  in  cases  of  doubt  the  mi- 
croscope will  decide. 

Treatment. — The  surfaces  in  the  neighborhood  of  the  eschars 
should  be  cauterized  with  nitrate  of  silver  for  the  purpose  of 
modifying  them  and  opposing  the  extension  of  the  disease. 
Washing  with  disinfectants  should  be  frequently  practiced  by 
means  of  a  hair-pencil  dipped  in  a  i  %  solution  of  carbolic  or 
salicylic   acid. 


590  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

The  patient  should  be  left  as  long  as  possible  without  the 
canula. 

Gangrene  of  the  edges  and  of  the  neighborhood  of  the 
wound  demands  the  same  attention.  If,  though  such  cases  are 
very  rare,  the  lesions  extend  beyond  the  surface  of  the  shield 
of  court  plaster,  this  can  be  enlarged  ;  or  it  is  well  to  place 
over  the  diseased  parts  leaves  of  blotting  paper  covered  with 
cerate  or  cold  cream  to  diminish  the  friction  from  the  tapes. 

When  the  eschars  have  been  detached,  the  wound  is  found 
in  ordinary  conditions;  and  there  remains  nothing  more  than 
to  direct  the  cicatrization  according  to  the  principles  which  I 
shall  indicate  hereafter.  In  the  midst  of  the  attentions  which 
the  local  condition  demands,  those  must  not  be  forgotten 
which  are  demanded  by  the  general  condition.  Alimentation, 
quinine  and  generous  wines  form  an  indispensable  supplement 
to  the  treatment. 

Diphtheria  of  the  Wound. 

We  know  the  tendency  which  diphtheria  has  to  every  point 
of  the  cutaneous  surface,  which  is  deprived  of  epidermis,  and 
with  what  facility  the  false  membranes  extend  over  blistered 
surfaces  and  over  ulcerations  of  every  kind.  Diphtheritic  com- 
plication of  the  wound,  therefore,  appears  to  be  the  fatal  con- 
sequence of  these  two  causes  united,  viz.,  diphtheria  and  tra- 
cheotomy. But  it  is  not  so,  for  diphtheria  of  the  wound  is  not 
as  common  as  we  would  be  tempted  to  believe.  The  false 
membrane  appears  more  readily  upon  a  cutaneous  surface 
which  is  ulcerated,  or  only  deprived  of  its  epithelium,  than 
upon  a  wound  involving  the  deep  parts.  From  this  result  the 
infrequency  of  diphtheria  of  the  wound  and  its  tendency  to 
settle  upon  the  surface,  on  a  level  with  its  edges,  where  the 
skin  is  cut,  rather  than  upon  the  walls  themselves.  The  an- 
atomy explains  this  peculiarity,  for  the  histological  elements 
which  furnish  the  pseudo-membranous  exudate  are  the  epi- 
thelial cells  and  those  of  the  rete  mucosum  of  Malpighi. 
These  do  not  exist  in  the  depths  of  the  wound,  hence  the   rar- 


SEQUELAE  OF  TRACHEOTOMY.  59 1 

ity  of  the  false  membrane  in  those  regions.  In  a  case  where  it 
should  really  form  'rt  would  be  at  the  expense  of  the  cells  of 
the  connective  tissue  which,  moreover,  is  rare  in  the  deep  por- 
tions. If  it  has  appeared  common  to  many  authors  it  is  be- 
cause they  have  often  confounded  it  with  gangrene. 

Diphtheria  of  the  wound  begins  from  the  second  to  the 
fourth  day  after  the  operation.  The  wound  swells,  its  walls 
become  indurated  and  the  opening  enlarges.  The  aspect  of 
the  lesion  varies  according  to  its  site.  Upon  the  walls  of  the 
wound  it  appears  under  the  form  of  white  patches,  sometimes 
slightly  yellow,  adherent  and  thin  about  the  edges.  The  su- 
perior and  inferior  angles,  and  particularly  the  superior  angle, 
are  its  habitual  site.  We  remark  that  the  points  where  diph- 
theria is  encountered  are  those  where  the  compression  of  the 
canula  is  the  least  felt,  and  of  all  these  points  the  superior 
angle  is  certainly  the  one  which  is  the  least  compressed.  After 
that  comes  the  inferior  angle,  and  finally,  the  walls.  Would 
compression  be  an  obstacle  to  the  development  of  diphtheria? 
If  it  fixes  upon  the  edges,  it  disposes  itself  about  the  wound 
under  the  form  of  a  narrow  border,  which  is  oftenest  encoun- 
tered at  the  level  of  the  angles,  and  especially  that  of  the  su- 
perior angle,  from  whence  it  descends  along  the  edges,  form- 
ing a  sort  of  crescent. 

Diphtheria  of  the  wound  has  little  tendency  to  spread  and 
in  this  respect  it  differs  from  diphtheria  of  the  mucous  mem- 
brane. The  marginal  false  membranes  are  perhaps  those 
which  have  the  greatest  tendency  to  gain  ground.  They  be- 
come, moreover,  cutaneous  diphtheria.  But  this  accretion  is 
not  very  great  and,  besides,  we  should  not  allow  ourselves  to 
be  deceived  by  the  ulcerative  inflammation  which  often  devel- 
ops about  the  false  membrane;  for  the  pus  which  the  ulcer  se- 
cretes, and  its  slightly  grayish  floor,  by  being  confounded  with 
the  tint  of  the  false  membrane,  seem  to  augment  the  territory 
of  the  latter.  A  careful  examination  made  after  washing  the 
surfaces  allows  the  situation  of  the  respective  changes  to  be 
exactly  recognized. 

When  diphtheria  alone  is  present  in  the  wound,   the   canula 


592  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

remains  bright,  but  since  it  is  very  rare  that  a  slight  amount  of 
gangrene  is  not  associated  with  it,  the  black  discoloration  of 
the  metal  is  quite  often  observed.  The  general  condition  pre- 
sents nothing  special  to  be  noted. 

Prognosis. — Diphtheria  of  the  wound,  is  not,  of  itself,  an  in- 
dication of  great  gravity,  for  of  all  the  complications  which 
affect  this  region,  it  is,  to  a  certain  extent,  the  most  natural 
one,  since  it  is  only  a  slightly  important  localization  of  the  dis- 
ease, and  has  not,  therefore,  in  many  cases  other  than  a  local 
importance  which  is  proportional  to  the  extent  of  the  surfaces 
invaded.  Nevertheless  when  it  persists  for  a  long  time,  and 
when  it  assumes  a  tendency  to  propagate  or  reproduce  itself, 
the  prognosis  becomes  more  serious,  for  it  is,  in  fact,  a  proof 
of  the  intensity  and  tenacity  of  the  general  affection.  It  has, 
moreover,  the  inconvenience  of  becoming  often  complicated 
with  gangrene. 

Diagnosis. — Diphtheria  of  the  wound  can  only  be  con- 
founded with  gray  ulceration  and  with  gangrene.  The  dis- 
tinctive signs  of  these  three  morbid  conditions  have  been  given 
in  the  article  gangrene. 

Treatment. — What  I  have  previously  said  of  the  local  treat- 
ment of  false  membranes  is  applicable  here.  Caustics  should 
be  ruled  out  as  in  every  other  case.  Recourse  should  prefera- 
bly be  had  to  astringents,  e.  g.,  alum,  tannin,  or  better  still,  to 
solvents  of  the  false  membrane,  such  as  lemon-juice,  lactic  acid, 
and  lime-water.  A  hair-pencil  lightly  dipped  in  one  of  these 
liquids  should  frequently  be  passed  over  the  walls  of  the 
wound.  If  there  be  gangrene  at  the  same  time,  recourse 
should  be  had  to  the  appropriate  treatment.  When  the  false 
membrane  has  extended  to  the  surrounding  skin,  a  coating  of 
glycerate  of  tannin  should  be  spread  over  the  diseased  parts, 
or,  indeed,  they  may  be  powdered  with  a  mixture  of  equal 
parts  of  starch  powder  and  tannin.  They  may  also  be  cov- 
ered with  a  pledget  of  charpie  dipped  in  a  solvent  liquid.  The 
dressing  should  be  renewed  two  or  three  times  a  day.  When 
the  canula  is  to  be  put  in  place  the  surfaces  should  be  pro- 
tected by  sliding  pieces  of  the  dressing  underneath  the  tapes. 


sequels  of  tracheotomy.  593 

Irregularities  of  Cicatrization. 

We  have  seen  how  the  cicatrization  of  the  wound  behaves 
when  recovery  is  obtained  without  comphcations.  I  have  in- 
timated that  numerous  causes  might  influence  the  progress  of 
this  work,  either  by  retarding  it  or  by  preventing  its  progres- 
sion in  accordance  with  the  permeabihty  of  the  air-passages. 
In  the  natural  order  of  the  disease  there  is  a  parallehsm  be- 
tween the  cicatrization  of  the  wound  and  the  clearing  up  of 
the  larynx,  i.  e.,  when  the  latter  has  become  permeable  to  the 
air,  the  wound  tends  uninterruptedly  toward  cicatrization  and 
becomes  closed  in  a  very  few  days  after  the  final  removal  of 
the  canula.  By  virtue  of  numerous  causes,  this  equilibrium 
may  be  destroyed,  and  hence  we  see  the  wound  delaying  cica- 
trization after  the  respiratory  passages  are  already  free,  or 
tending  to  close  before  the  air-passages  have  become  unob- 
structed. We  have  thus  to  consider  a  tardy  cicatrization,  and 
a  rapid  cicatrization. 

Tardy  Cicatrization. — Causes  of  any  kind  may  retard  cica- 
trization. Among  them,  we  must  record  in  the  first  rank,  le- 
sions of  the  wound,  viz.,  phlegmon,  erysipelas,  gangrene  and 
diphtheria. 

Cicatrization  retarded  by  a  cause  of  this  class  usually  re- 
sumes its  regular  course  when  the  cause  has  disappeared.  In 
other  cases,  on  the  contrary,  in  spite  of  the  cessation  of  the  in- 
itial influence,  the  wound  remains  at  the  point  where  the  com- 
plication left  it,  and  shows  no  tendency  at  all  toward  recovery. 
Often,  moreover,  there  has  been  no  lesion  at  all  of  the  wound, 
the  respiratory  passages  are  free,  the  canula  has  been  removed, 
but  the  wound  remains  the  same  as  on  the  first  day.  It  is 
pale,  soft,  without  granulations,  and  does  not  make  a  single 
effort  toward  cicatrization.  With  other  patients,  finally,  the 
work  of  reparation  after  having  begun,  and  given  hope  of  an 
early  recovery,  is  suddenly  arrested.  These  difficulties  of  cicatri- 
zation are  never  manifested  without  grave  cause,  and  the  patient 
under  the  influence  of  a  complication,  either  apparent  or  hid- 
den.    By  complication  I  mean  not  the  lesions  of  the  wound 


594  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

which  habitually  present  themselves  shortly  after  the  opera- 
tion, but  affections  which  are  more  general  and  of  a  very  dif- 
ferent kind,  such  as  inflammations  of  the  respiratory  apparatus, 
eruptive  fevers,  diphtheritic  paralysis,  diphtheritic  cachexia, 
alterations  of  the  digestive  functions,  etc. 

When  a  cure  is  about  to  be  obtained,  cicatrization  resumes 
its  course,  and  the  wound  promptly  closes.  But  there  are  cases 
where  this  work  is  never  completely  revived  and  the  patient 
remains  with  a  tracheal  fistula.  These  instances  are  happily 
extremely  rare. 

Treatment. — Since  the  delay  in  cicatrization  is  the  expres- 
sion of  a  more  or  less  extensive  general  trouble,  the  cause, 
when  sought  for  and  discovered,  should  be  the  object  of  ap- 
propriate attention. 

The  local  treatment  consists  in  stimulating  applications.  The 
wound  should  be  touched  several  times  a  day  with  a  pencil 
dipped  in  a  I  %  solution  of  carbolic  acid.  This  means  has  fre- 
quently given  me  excellent  results.  If  it  be  not  sufficient  re- 
course should  be  had  to  superficial  cauterizations  with  nitrate 
of  silver. 

Premature  Cicatrization. 

There  are  cases  where  the  wound  tends  to  close  before  the 
respiratory  passages  are  free.  This  want  of  equilibrium, 
while  indeed  it  becomes  a  true  complication  by  reason  of  the 
troubles,  often  grave,  which  it  causes,  is  in  reality  only  the 
normal  course  of  cicatrization.  If,  in  the  greater  number  of 
cases,  cicatrization  follows  the  recovery  of  the  larynx,  this 
occurs  only  by  virtue  of  the  morbid  condition  which  involves 
the  whole  economy.  In  a  subject  who  undergoes  tracheotomy 
for  a  lesion  foreign  to  any  general  affection,  in  cases  of  foreign 
bodies  in  the  air-passages,  for  example,  cicatrization  is  pro- 
duced with  very  great  rapidity  and  it  is  the  same  in  other  in- 
juries of  the  larynx. 

Just  as  slowness  of  cicatrization   indicates    a   profound    im- 
pregnation of  the  economy,  so  rapidity  of  cicatrization  corres- 


SEQUELS  OF  TRACHEOTOMY,  59$ 

ponds  with  an  intoxication  which  is  feeble  or  already  neutral- 
ized. A  favorable  prognosis  can  be  given  in  such  a  case.  The 
local  condition  often  remains,  it  is  true,  difficult  to  manage, 
and  requires  minute  attention  ;  but  we  should  deem  ourselves 
happy  when  diphtheria  loses  its  infectious  character  to  be- 
come, after  a  sort,  transformed  into  a  local  lesion,  accessible  to 
treatment.  In  some  cases,  very  rare  ones,  however,  cicatriza- 
tion may,  by  reason  of  the  slight  importance  of  the  intoxica- 
tion, and  by  reason  of  the  vigor  of  the  subject,  precede  the 
clearing  up  of  the  larynx,  even  when  the  lesions  of  this  organ 
show  neither  exceptional  intensity  nor  persistence.  With 
other  patients  priority  of  cicatrizaticjn  reveals  itself  later,  after 
having  been  retarded  either  by  the  low  general  condition  or 
by  local  complications,  e.  g.,  diphtheria,  gangrene,  etc.  In 
other  cases,  finally,  while  cicatrization  follows  a  regular  course, 
the  larynx  is  slow  in  becoming  permeable  again.  Whatever 
be  the  cause,  the  symptoms  and  the  treatment  are  the  same. 
Whether  the  wound  be  still  recent  and  healthy,  or  of  long 
standing  and  has  remained  healthy,  or  has  become  clean,  it 
granulates  actively  and  rapidly  closes.  Every  time  the  canula 
is  withdrawn,  the  skin  contracts  little  by  little  and  narrows  the 
lumen  of  the  wound,  so  much  so  that  often  in  a  very  short  time 
the  air  can  no  longer  pass  through  this  opening  without  diffi- 
culty. Respiration  becomes  embarrassed,  the  face  blue  and  anx- 
ious, retraction  is  produced,  and  an  actual  attack  of  suffocation 
comes  on,  so  intense  at  times  that  if  it  be  not  relieved,  the 
child  succumbs  without  delay.  Sometimes  this  occurs  with 
such  rapidity  that  if,  unfortunately,  the  patient  be  alone  or 
those  about  him  be  unable  to  replace  the  canula  (an  opera- 
tion which  in  such  circumstances  may  become  difficult)  as- 
phyxia comes  on  and  destroys  a  child  who  was  already  nearly 
well.  If  the  canula  have  remained  a  short  time  out  of  the 
wound  and  the  latter  have  undergone  but  a  moderate  con- 
traction, a  certain  resistance  is  experienced  on  reintroducing  it 
which  is  quite  easily  overcome,  but  if  the  contraction  has  been 
pushed  further,  the  obstacle  becomes  more  serious  ;  for  the 
opening,  reduced  to  a  very  narrow  passage,  refuses  to    distend 


50  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

and  admit  a  canula  of  the  same  calibre.  We  will  oftenest  suc- 
ceed, however,  after  several  unsuccessful  attempts,  by  pressing 
the  end  of  the  canula  against  the  wound  and  especially  by 
giving  the  instrument  a  double  rotary  movement,  as  in  the 
management  of  an  awl.  It  will  then  be  noted  that  the  resis- 
tance is  superficial,  and  that  when  once  the  cutaneous  ring  is 
passed,  the  canula  glides  easily  along  the  rest  of  its  course. 
This,  is  at  least,  what  I  have  observed  in  every  patient,  and  the 
elasticity  of  the  skin,  much  more  energetic  than  that  of  the  sub- 
jacent tissues,  explains  this  peculiarity.  In  one  case  I  met 
with  a  second  obstacle  a  little  distance  from  the  sk^n,  which, 
perhaps,  was  due  to  fibrinous  bands  in  front  of  the  trachea.  It 
is  not  unusual  that,  in  spite  of  repeated  trials,  the  canula  which 
the  patient  has  habitually  worn  cannot  be  made  to  re-enter, 
and  we  are  compelled  to  take  a  smaller  size  ;  but  in  some 
cases  the  resistance  is  so  great  as  to  necessitate  its  removal  by 
incision. 

This  situation  persists  up  to  the  time  when  the  larynx  has 
returned  to  its  normal  condition,  provided  always,  that  the 
general  condition  of  the  child  remains  satisfactory  ;  if  not,  the 
wound  relaxes  and  cicatrization  is  arrested  until  the  new  mor- 
bid element  has  disappeared  when  it  resumes  its  course  with 
the  same  tenacity.  I  have  published  the  history  of  a  child  in 
whom  the  wound  had  an  extreme  tendency  to  become  obliter- 
ated, measles  intervened,  the  wound  at  once  reopened,  became 
soft  and  allowed  the  canula  to  enter  easily  ;  and  when  the  ex- 
anthema disappeared  the  wound  began  to  recontract. 

From  the  time  when  the  state  of  the  larynx  at  last  permits 
the  final  removal  of  the  canula  the  wound  closes  as  if  by  en- 
chantment. In  a  day  or  two  it  becomes  covered  with  a  scab, 
beneath  which  cicatrization  is  perfected.  Granulations  may, 
by  their  volume  and  mobility,  precipitate  the  occlusion  of  a 
wound  which  is  already  cicatrizing  too  rapidly.  In  the  little 
patient  of  whom  I  have  just  spoken,  the  superior  angle  of  the 
wound  gave  rise  to  a  large  mass  of  fungous  granulations  which 
being  free  below,  was  a  fair  representation  of  the  form  of  the 
uvula,  and  possessed  a  like  mobility.     As   soon   as   the    child 


SEQUELS  OF  TRACHEOTOMY.  597 

was  without  the  canula,  the  air  passing  through  the  wound 
drew  the  mass  toward  the  trachea,  making  a  stopper  of  it, 
which  checked  the  respiration. 

Treatment. — The  causes  which  retard  the  permeabihty  of  the 
larynx  should  be  the  object  of  the  first  attention.  See,  laryn- 
geal complications. 

We  should  watch  carefully  to  see  that  the  child  does  not  re- 
main without  the  canula  long  enough  for  the  contraction  to  be- 
come  insurmountable;   but  with  a  little   experience   the  mo- 
ment will  be  recognized  when  the  wound,  although  contracted 
will  yet  admit  the  canula  without  great   difficulty.     But  there 
are  wounds  which  do  not  allow  even  this  latitude  ;  for  scarcely 
is  the  canula  removed  before  the  skin  contracts  and  the  orifice 
closes.     It  is  then  necessary  to  cleanse  the  wound  speedily,  to 
take  a  canula  and  replace  it ;  for  all  delay  will  be  the  cause  of 
new  obstacles.     If  the  constriction  of  the   wound   is   energetic 
enough  for  asphyxia  to  become  imminent,  a   dilator  should  be 
rapidly   introduced   into  the   wound ;  the  separation   which  is 
obtained,  is  enough  to  allow  the   respiration  to  be  established, 
but    is    too    little  to  permit  the  passage  of  the  canula.  The  di- 
lator should  then  be  kept  in  the  wound  for   some   moments  to 
allow  the   patient   to  become   tranquillized,  and  the  occasion 
should  be  improved  by  opening  several  times  forcibly  the  jaws 
of  the  instrument,  in  such  a  way  as  to  overcome  the   resistance 
of  the  tissues.     The  trachea  is  then  seized  between  the  thumb 
and  middle  finger  of  the  left  hand  and   slightly  lifted  up,  then 
the  canula  is  applied  with  the  right  hand   and  entered  without 
violence,  and  always  with  a  rotary  movement.    Inconsequence 
of  these   maneuvers,  the  skin   gradually  relaxes,  and   when  it 
finally  yields,  a  sensation  of  resistance  overcome,  is   felt.     The 
dilator  which   is  of  great  service  in  the  matter  of  partly  open- 
ing the  wound,  and  even  of  dilating  it,  becomes  useless  and  in- 
convenient   in    the    introduction  of  the   canula.     It  should  be 
laid    aside.     We    are    no    longer,  in   fact,  in    the    situation   of 
tracheotomy,when  the  freshly  cut  tissues  are  supple  and  easily 
yield  to    pressure  ;  the   borders   of  the  wound  have  lost  their 
flexibility  and  offer  resistence  to  dilatation.     The  result  is  that 


59^  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

the  forceps  not  only  separates  them  but  little,  but  its  blades 
occupy  a  space  which  still  further  diminishes  the  room  left  for 
the  canula  ;   so,  instead  of  aiding,  it  hinders. 

By  this  procedure  we  often  succeed  in  replacing  a  canula  of 
the  same  size.  There  are  circumstances  where  all  efforts  re- 
main ineffectual;  and  then  it  is  that  the  valvular  canula  ot' 
Bourdillat  has  been  of  great  service  to  me.  This  instrument  is 
introduced  like  the  bivalve  speculum  of  Ricord,  to  which  it  has 
a  great  analogy  ;  while  its  almost  linear  extremity  often  per- 
mits it  to  overcome  the  stricture.  When  once  the  external 
canula  is  put  in  place  the  internal  canula,  which  is  cylindrical 
and  rigid,  is  introduced  and  it  neer's  only  to  be  pushed  forcibly 
into  the  external  canula  whose  valves  it  separates.  When  it 
is  introduced  completely  the  valves  are  separated  and  the  track 
from  the  skin  to  the  trachea  is  reestablished.  To  give  more 
power  to  it,  I  have  had  made,  by  Collin,  an  obturator  with 
wooden  handle  large  enough  to  be  grasped  by  the  whole  hand, 
like  that  of  a  trocar  for  paracentesis  of  the  abdomen.  The  in- 
strument thus  modified  affords  a  firm  hold  which  permits  it  to 
pass  strictures  before  which  it  formerly  recoiled. 

When  the  passage  has  been  forced,  this  canula  can  be  with- 
drawn and  replaced  b>'  an  ordinary  canula,  which  maneuvre 
is  accomplished  without  difficulty.  But  dilatation  may  remain 
insufficient,  the  necessary  instruments  may  be  wanting  und  we 
have  as  a  last  resort  the  division  of  the  stricture  in  the  wound. 
To  perform  this  operation  the  patient  is  placed  in  the  proper 
position  and  secured  as  for  tracheotomy,  but  left  upon  his  bed. 
If  the  wound  will  admit  the  dilator  it  is  well  to  introduce  that 
instrument.  Its  jaws  are  slightly  separated  and  then,  with  a 
probe  pointed  bistoury  which  is  passed  between  them,  the 
stricture  is  cut,  care  being  taken  to  include  in  the  incision  the 
whole  thickness  of  the  tissues,  from  the  skin  to  the  trachea  in- 
clusive. This  precept  is  indispensable.  If,  in  fact,  the  inci.s- 
ion  stops  in  front  of  the  trachea,  risk  is  run  of  a  difficult  intro- 
duction of  the  canula,  and  of  false  passages  in  the  peri-tracheal 
connective  tissue.  This  accident  has  happened  several  times, 
and  I  have  found  it  related  in  two  observations. 

If  the  wound  is  too  narrow  to    allow  a  dilator    to    enter,  the 


SEQUELAE  OF  TRACHEOTOMY.  599 

probe-pointed  bistoury  is  at  once  introduced  and  pushed  care- 
fully from  before  backward  until  it  encounters  a  resistence. 
When  it  is  quite  certain  that  this  resistance  is  due  to  the  pos- 
terior wall  of  the  trachea,  the  cut  should  be  made.  If  there  be 
doubts  as  to  the  depth  of  the  incision  the  dilator  should  be  in- 
troduced and  the  wound  inspected,  and  if  the  trachea  has  not 
been  included  in  the  incision  it  is  easy  to  complete  it  by  re- 
peating the  former  procedure.  In  what  direction  should  the 
incision  be  made?  That  is  almost  a  matter  of  indifference  and 
depends  on  circumstances.  Whatever  be  the  direction  of  the 
cut,  it  should  be  made  in  the  median  line  in  order  to  avoid  ir- 
regular wounds  of  the  trachea  out  of  line  with  that  of  the  soft 
parts. 

The  extent  of  the  cut  in  the  greater  number  of  cases,  should 
not  exceed  half  a  centimeter.  The  introduction  of  the  canula 
is  usually  very  easy  and  it  enters  without  the  aid  of  a  dilator. 
This  instrument  would  be,  moreover,  of  more  harm  than  use 
for  the  reason  previously  indicated.  Bourdillat's  canula  would 
be  very  useful  in  case  of  difficulty. 

When  the  respiration  is  obstructed  by  large,  moveable 
masses  of  granulations,  they  should  be  thoroughly  cauterized 
every  day.  This  means  is  often  insufficient,  especially  when 
the  granulations  are  deep  in.  In  such  a  case  they  should  be 
torn  off  by  means  of  forceps  introduced  into  the  wound  at  the 
instant  when  expiration  forces  the  tumor  outward.  After  be- 
ing torn  off,  the  stump  should  be  cauterized. 

Accidents  Subsequent  to  Cicatrization. 

All  has  not  yet  been  said  with  regard  to  the  wound  in  the 
integument  when  it  has  cicatrized.  Contractions  and  deformi- 
ties result  from  considerable  losses  of  substance  occasioned  by 
gangrene.  Moreover,  the  newly  formed  tissue  is  exposed  to 
ulceration  and  even  to  destruction.  It  has  been  seen  that  cer- 
tain morbid  general  conditions  retard  or  interrupt  the  work  of 
reparation.  Their  influence  may  be  felt,  even  after  cicatriza- 
tion is  complete.  Eruptive  fevers,  or  pulmonary  inflammations 
which  arise  shortly  after  this  stage,  often  ulcerate   the    cicatrix 


6oo 


DIPHTHERIA,    CROUP    A\U    TRACH  KOTOMY. 


and  even  reopen  it  completely  so  far  as  to  include  the  trachea. 
With  one  child,  the  wound  which  had  been  cicatrized  for  sev- 
enteen days,  reopened  under  the  influence  of  a  pleurisy  and 
laid  bare  the  trachea.  The  same  accident  occurred  in  another, 
two  months  after  cicatrization,  and  was  occasioned  by  pneu- 
monia. A  third,  who  had  gone  out  of  the  hospital  sev^eral 
months  before,  returned  with  an  abscess  developed  without 
apparent  cause  at  the  level  of  the  cicatrix.  The  abscess  dis- 
charged itself,  but  ulcerated  the  cicatrix.  The  ulcerative  process 
gained  in  breadth  and  depth  till  it  reached  the  treachea,  which 
in  its  turn  reopened.  After  some  days  cicatrization  resumed 
its  work ;  and  the  wound  finally  closed  in  fifteen  days. 

Of  these  three  patients,  only  one  succumbed  to  the  inter- 
current disease,  and  that  was  the  one  who  was  attacked  with 
pneumonia.  The  other  two  recovered  rapidly  and  completely 
as  soon  as  the  influence  which  compromised  the  nutrition  of 
the  tissues  disappeared. 


CHAPTER    II. 


ACCIDENTS  WHICH  DEPEND    UPON    THE   TRACH- 
EAL  WOUND. 

Ulcerations  of  the  trachea,tracheo-laryngeal  strictures,polypi 
of  the  trachea,  and  fistulae, 

ULCERATIONS  OF  THE  TRACHEA. 

The  anatomico-pathological  division  of  this  question  has 
been  treated  at  the  beginning  of  this  work.  The  symptoms, 
the  diagnosis,  the  etiology,the  prognosis  and  the  treatment,re- 
main  to  be  pointed  out. 

SYMPTOMS    AND    DIAGNOSIS. 

Since  ulcerations  of  the  trachea  are  inaccessible  to  sight, 
tney  are  perceptible  only  by  means  of  rational  symptoms.  As 
they  are  most  commonly  produced  in  consequence  of  trache- 
otomy, the  sii  n  ;  by  which  they  are  recognized  are  inferred 
from  the  condit  on  of  the  canula,  and  from  the  quality  of  the 
expectoration.  These  are:  ist.  TJie  black  discoloration  of  the 
beak  of  the  canula. — The  tracheal  ulceration  being  of  a  gan- 
grenous nature,  it  blackens  the  lower  end  of  the  canula  just  as 
gangrene  of  the  wound  blackens  the  upper  portions.  This  is 
a  sign  which  is  never  wanting ;  and  on  the  other  hand,  the  end 
of  the  canula  does  not  change  when  the  tracheal  wall  is  not  ul- 
cerated. When  gangrene  attacks  the  wound  and  the  trachea 
at  the  same  time,  it  is  not  rare  to  see  the  two  extremities  of  the 
tube  blackened  and  separated  by  an  intact  zone.  This  is  the 
best  sign  of  tracheal  ulceration.  The  canula  is  the  reagent 
which  discloses  the  lesion. 

2d.    The  expectoration  of  sanginneous  mucous  sputa  thrown  ofp 

(6oi) 


602  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

sevetal  days  after  traclicotoniy. — These  should  be  distinguished 
from  the  sputa  mixed  with  blood  which  follow  tracheotomy 
during  the  first  few  days.  The  latter  are,  in  fact,  the  conse- 
quence of  an  oozing  of  blood,  which  persists  at  the  level  of  the 
wound,  or  of  an  effusion  of  blood  into  the  trachea  at  the  time 
of  operation.  Those  which  come  from  an  ulceration  only  ap- 
pear several  days  after  the  expectoration  has  become  free  from 
blood. 

3d.  A  fetid,  gang7'e7io2is  odor  exhaled  by  the  100201  d,  may  be  a 
good  sign  of  ulceration,  but  it  is  very  often  liable  to  lead  into 
error.  If  the  wound  be  gangrenous  it  may  produce  this  odor. 
It  has  no  value  respecting  the  existence  of  an  ulceration  unless 
it  is  perceived  when  the  wound  is  healthy.  In  this  case  it  can 
be  perfectly  ascertained  every  time  the  canula  is  introduced  ; 
for  after  the  wound  is  well  washed,  and  free  from  odor,  at  that 
moment  a  puff  of  fetid  air  is  perceived  to   pass  through  it. 

4th.  Paiji  in  the  anterior  cervical  region  notedhy  Toulmonche. 
The  child  frequently  carries  its  hand  toward  the  neck  with  a 
very  evident  expression  of  suffering.  This  sign  may  be  valid, 
as  I  myself  have  verified.  But  it  has  no  value  unless  the  ex- 
ternal wound  is  healthy,  and  when  there  is  neither  inflamma- 
tion nor  erysipelas  in  its  neighborhood. 

The  bad  condition  of  the  wound,  and  of  the  soft  parts  of  the 
neck,  their  tumefaction,  and  their  gangrenous  or  ulcerated 
condition  indicated  by  Roger  as  one  of  the  signs  of  tracheal 
ulceration,  may  coexist  with  this  ulceration,  but  it  appears  in 
too  many  cases  where  the  ulceration  does  not  exist,  to  give  it 
the  claim  to  be  regarded  as  of  importance. 

The  same  is  true  with  regard  to  dysphagia. 

Etiology. 

General  and  local  causes  influence  the  formation  of  these  ul- 
cerations. Locally,  the  pressure  of  the  canula  is  the  usual 
agent.  As  the  surface  of  the  tube  produces  necrosis  of  the 
walls  of  the  wound  by  the  pressure  which  it  exercises  upon 
them,  so   also  the  beak  of  the  instrument  causes    that    portion 


SEQUELAE  OF  TRACHEOTOMY.  603 

of  the  tracheal  wall  in  contact  with  it,  to  mortify.     In  fact,  the 
ulcerations  almost  always  occupy  this  situation,  and  when  they 
extend   around  the  whole   circumference  of  the  trachea,  their 
maximum  depth  is  found  upon  the  anterior  portion.     Formerly 
the  ulcers  were  more  frequent  at  the  back  part,  on   account  of 
the  construction  of  the  canulas.     The  curve  of  the  metallic  tube 
being  copied  after  the  quadrant  ot  a  circle,  presented  posteri- 
orly a  quite  salient  convexity  which,  bearing   against  the   pos- 
terior wall  of  the  trachea,  pressed  upon  it,  and  of  necessity    ul- 
cerated it.     The  immobility  of  the  two  pieces  of  the  canulaone 
upon   the  other,  /.  c.  the  soldering    of  the  tube  to   the  flange, 
favored  ulceration  by  exposing  the  trachea  to    friction  against 
the  canula  during  the  movements  of  ascent  and   descent  which 
result  from  respiration,  cough  and    deglutition.     The    exterior 
flange  being  held  immovable  by  the  tapes,  the  vertical  portion, 
in  place  of  following  the  trachea,  resisted   and   rubbed   against 
it.  Large  sized  canulas,  too  large  for  the  calibre  of  the  trachea, 
have  a  similar  action.     As  they  are  in  more    complete    contact 
with  the  mucous  membrane,  they  exercise    a   more  continuous 
pressure  and  may  ulcerate  the  trachea  over  a  large  surface  and 
in  every  direction.     The  inferior  orifice  of  the  canula,  when  it 
is  circular  and  perpendicular  to  the  axis  of  the    tube,  forms  in 
front,  an  almost  cutting  edge  which   rapidly  abrades   and   per- 
forates the  anterior  wall  of  the  trachea.     The  effect  of  the  local 
cause    is    still    further  shown   by  an  instance  cited  by  Hayem. 
Tracheal  ulcerations  were  found  in  a  man   who   was   operated 
upon  for  compression  of  the  trachea  due  to  a  glandular  tumor. 
In  this  case  the  influence  of  the   general   condition   could    not 
be  assigned.     But  if  mechanical  action  is   evident   in  the  pro- 
duction of  tracheal  ulceration,  that  of  the  general   condition   is 
none  the  less  so,  and  may  even  be  sufficient  to  account   for  it. 
In  fact,  ulcerations    do    not  always  form  in   proximity  to  the 
canula,  and  there  are  those  which  appear  beyond  the  reach  of 
the  instrument,  ulcerations   of  the  larynx,  for  example,  which 
could  not  be  attributed  to  compression,  are  found  at  the  same 
time.     Moreover,  a  goodly  number  of  tracheal   ulcerations  co- 
incide with  gangrene  of  the  wound  of  which  they  are  some- 


604  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

times  the  evident  extension.  If  pressure  of  the  canula  were 
the  sole  cause  of  the  ulceration,  no  one  who  is  operated  upon 
could  avoid  this  lesion.  Yet,  it  is  very  rare  in  the  absence  of 
diphtheria. 

Patients  tracheotomized  for  oedema  of  the  glottis,  syphilitic 
lesions  or  polypi  of  the  larynx  wear  their  canula  for  months  or 
years  without  the  trachea  becoming  necrosed.  Finally, 
among  the  ulcerations  which  are  verified  post  mottem,  the 
deepest  are  not  always  those  which  coincide  with  the  longest 
retention  of  the  canula.  Thus  Roger  cites  two  perforations, 
the  one  accomplished  in  five  days  and  the  other  in  thirty-six 
hours.  On  the  other  hand,  in  a  patient  who  died  at  the  end 
of  twenty-seven  days,  there  was  found  only  a  very  slight 
erosion. 

There  are  then  two  influences,  one  local  and  efficient,  the 
other  general  or  predisposing,  which  unite  in  engendering  ul- 
ceration. The  most  powerful  one  is  certainly  the  second,  as 
the  long  sojourn  of  the  canula  without  accident  in  non-infec- 
tious cases,  and  on  the  other  hand,  the  lesions  which  super- 
vene after  a  very  short  sbjourn  in  cases  of  profound  blood 
poisoning,  fully  prove. 

The  predisposing  causes  are  :  diphtheria  in  its  infectious  or 
malignant  forms,  gangrene  of  the  wound,  diseases  of  the  res- 
piratory passages  which  predispose  the  mucous  membrane  by 
inflaming  it  and  altering  its  nutrition  ;  and  tender  years — ul 
ceration  is  especially  encountered  among  patients  aged  about 
2  years.  The  type  of  the  prevailing  disease  (epidemic  or 
meteorological  influences)  is  also  of  great  importance,  for  in 
certain  epidemics  tracheal  ulceration  is  rare,  while  in  others  it 
is  frequent. 

Frequency. 

Ulceration  of  the  trachea  often  passes  unnoticed  during  life, 
the  autopsy  alone  disclosing  it.  The  conclusion  must  not  be 
drawn  from  this  that  the  lesion  is  extremely  rare.  It  must 
often  escape  notice  among  patients  who  recover,  in  view  of  the 


SEQUELiE  OF  TRACHEOTOMY.  605 

insufficiency  of  the  means  of  diagnosis.  Everything  leads  to 
the  belief  that  it  is  more  frequent  than  the  cases  collected  at 
the  autopsy  would  seem  to  indicate. 

Prognosis. 

Tracheal  ulceration  is  curable,  and  the  gravity  of  the  cases 
in  which  it  is  encountered,  depends  not  on  the  ulceration,  but 
upon  the  intensity  of  the  diphtheritic  poisoning.  It  is  no  lon- 
ger so  when  the  cartilaginous  rings  are  eroded,  and  when  the 
c  inula  bears  against  a  membrane  which  has  grown  very  thin 
for  perforation  is  imminent  and  is  effected,  unless  another  and 
graver  complication  precedes  it.  The  perforations  which  I 
have  observed  did  not  appear  to  have  of  themselves  fatal  con- 
sequences, and  death  did  not  seem  to  be  properly  attributable 
to  them.  Yet,  one  of  them  coincided,  as  in  a  patient  of 
Roger's,  with  a  pretracheal  abscess.  In  four  of  my  cases,  the 
ulceration  showed  a  curious  relation  ;  it  corresponded  with  the 
innominate  trunk,  from  which  the  canula  was  separated  by 
only  a  very  thin  membrane.  In  one  case  the  lower  end  of  the 
instrument  was  in  direct  relation  with  this  vessel.  It  is  proba- 
ble that  if  the  disease  had  lasted  longer,  the  ulceration  would 
have  extended  to  the  vascular  walls  and  perforated  them, 
giving  rise  to  a  frightful  haemorrhage. 

There  have  been  cited  several  cases  of  haemorrhage  of  this 
kind,  supervening  in  adults  who  had  worn  a  canula  for  several 
months  after  tracheotomy  performed  for  organic  lesions  of  the 
larynx.  Roger  cites  two  remarkable  examples  of  this  kind. 
This  termination  is  extremely  rare  in  children,  and  the  only 
two  cases  I  know  of  were  quite  recently  reported  by  Howse  ; 
haemorrhage  came  on  suddenly  and  was  fatal. 

Can  the  inflammation  developed  in  the  mucous  membrane 
serve  as  the  point  of  origin  of  a  bronchitis  ?  I  reported  a  case 
in  which,  from  the  ulceration,  this  membrane  was  inflamed  as 
far  as  the  minute  bronchi,  while  the  portion  situated  above  the 
ulceration  remained  healthy.  It  may  be  asked  whether  the 
irritation  provoked  by  the  canula  upon  a  predisposed  mucous 
membrane  was  not  the  determining  cause  of  the  inflam.matory 
process. 


6o6  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

When  recovery  is  reached  in  spite  of  a  somewhat  extensive 
ulceration,  the  cicatricial  contraction  gives  rise  to  strictures  of 
the  trachea  which  are  encountered  in  certain  autopsies  made 
a  long  time  after  tracheotomy.  They  are  often  slightly  marked 
and  do  not  produce  any  functional  trouble  whatever ;  others, 
on  the  contrary,  are  more  decided  and  become  the  cause  of 
accidents. 

Treatment. 

The  really  important  part  of  treatment  is  prophylaxis. 
When  the  lesion  is  once  produced,  curative  treatment  is  very 
limited  in  default  of  feasible  topical  medication.  General  and 
local  measures  concur  in  preventing  it. 

General  medication  is  necessary  to  meet  the  general  predis- 
posing influence.  Alimentation  and  tonic  and  ferruginous 
preparations  hold  the  foremost  place.  The  few  local  measures 
which  are  at  our  disposal  are  likewise  valuable.  The  canula,  the 
immediate  cause  of  the  ulceration,  should  befixed  in  such  a  way 
as  to  diminish,  as  far  as  possible,  its  friction  against  the  mucous 
membrane. 

Since  the  principal  causes  which  make  this  instrument  the 
offending  agent  are,  the  immobility  of  the  collar  upon  the 
tube,  the  curve  of  the  latter  in  the  quadrant  of  a  circle  and  the 
salient  edge  of  its  lower  border,  modifications  have  been  made 
in  its  construction.  Luer  has  disposed  of  the  first  by  making 
canulae,  the  two  pieces  of  which  are  moveable.  The  vertical 
portion  is  easily  carried  along  by  the  trachea  in  the  ascending 
movement  and  falls  back  by  its  own  weight  in  the  descending 
movement;  but  sometimes  when  the  canula  is  too  large  and 
too  long,  the  room  given  to  the  vertical  portion  is  not  enough 
and  the  canula  continues  to  wound  the  trachea. 

The  same  maker  has  remedied  the  second  cause  by  enlarg- 
ing the  curve;  the  lower  end  being  carried  further  back  is  in 
less  close  contact  with  the  anterior  wall.  Barthez  provided  for 
the  third  inconvenience.     (See  p.  511  and  552). 

The  custom  of  removing  the  canula  as   soon   as   possible    is 


SEQUELS  OF  TRACHEOTOMY.  GO/ 

an    excellent    prophylactic    measure.       When    ulceration    has 
been  produced  and  diagnosticated,  what  should  be  done  ? 

All  local  treatment,  such  as  cauterization  of  the  trachea, 
should  be  avoided.  This  expedient,  already  dangerous  of 
itself,  cannot  be  applied  except  haphazard  in  view  of  the  ab- 
sence of  precise  notions  as  to  the  site,  the  extent  and  the 
depth  of  the  ulceration.  The  only  rational  treatment  consists 
in  removing  the  canula  every  day  as  long  as  the  patient  can 
permit  it,  and  in  taking  it  out  altogether  as  soon  as  practicable. 

Tracheo-Laryngeal  Strictures. 

These  are  caused  by  losses  of  substance  produced  by  ulcer- 
ations of  the  trachea,  or  by  certain  errors  in  operation.  Tra- 
cheal ulcerations  are  sometimes  accompanied  by  considerable 
destruction  of  tissue,  the  most  dangerous  being  those  which 
occupy  the  edges  of  the  incision,  for  they  enlarge  it  by  exca- 
vating in  its  lips  notches  of  more  or  less  depth.  Cauterization 
of  the  larynx  produces  the  same  results.  In  a  case  cited  by 
Bouchut,  a  child  attacked  with  membranous  pharyngitis  was 
subjected  to  cauterization  of  the  tonsils  with  a  pencil  saturated 
with  hydrochloric  acid.  A  drop  fell  into  the  larynx  and  pro- 
duced such  suffocation  that  it  became  necessary  to  perform 
tracheotomy.  The  patient  was  obliged  to  retain  his  canula 
because  of  the  stricture  which  was  produced  in  consequence 
of  this  burning  of  the  larynx. 

The  errors  in  operation  consist  in  multiple  incisions  of  the 
trachea  made  during  difficult  operations.  If  they  are  deep 
enough  they  result  in  detaching  more  or  less  extensive  frag- 
ments from  the  cartilaginous  rings.  In  either  case  there  is  a 
loss  of  substance  in  the  circumference  of  the  conduit,  whence 
there  often  results  cicatricial  contraction  followed  by  stricture. 
The  corresponding  symptoms  vary  with  the  tightness  of  the 
constriction.  When  this  is  very  close,  dyspncea  is  intense,  and 
respiration  cannot  be  carried  on  without  a  canula  without  dan- 
ger of  suffocation.  When  more  moderate  it  allows  the  child 
to  breathe  without  aid,    but   inspiration   is  accompanied   by  a 


6o8  DIPHTHIERIA,    CROUP    AND    TRACHEOTOMY. 

wheezing  which  lasts  a  great  while  and  which  augments  under 
the  influence  of  the  least  congestion  of  the  mucous  membrane. 
The  same  cause  brings  on  attacks  of  suffocation.  When  the 
lesion  affects  the  larynx  the  wheezing  is  accompanied  by 
hoarseness  of  the  voice. 

Three  patients  suffering  from  these  sequelae  of  croup  have 
passed  under  my  observation. 

The  first,  a  girl  of  2^2  years  old,  operated  upon  two  months  and  a  half  before, 
presented  retractio  1  accompanied  by  a  quite  intense  laryngo-tracheal  wheezing. 

The  second,  a  girl  of  the  same  age,  could  not  contract  a  cold,  a  year  even,  after 
tracheotomy,  without  bting  exposed  to  attacks  of  sufiocation. 

The  third,  a  girl  6  years  old,  was  subject,  for  two  years  following  the  croup,  to  at- 
tacks of  suffocation  which  returned  each  winter.  In  the  intervals  her  voice  was 
clear.  It  seemed  that  the  trachea  was  contracted  and  the  slightest  tumefaction  of  the 
mucous  membrane  sufficed  to  render  its  ca.ibre  too  narrow. 

Tracheal  strictures  always  possess  a  certain  gravity.  When 
tight  enough  they  force  the  patient  to  retain  the  canula,  and 
when  less  marked  they  expose  him  to  attacks  of  suffocation 
and  to  other  troubles  in  breathing  and  phonation.  Sometimes, 
even,  a  simple  cold  and  a  little  excitement,  suffice  to  deter- 
mine an  attack  of  suffocation  which  has,  in  several  cases,  been 
followed  by  death.  A  child  whose  history  Blachez  relates, 
had,  for  six  weeks  following  the  operation,  resisted  every  at- 
tempt to  remove  the  canula.  At  the  beginning  of  the  seventh 
week  Blachez  removed  the  canula  from  the  larynx,  but  left  it 
in  the  wound  for  the  purpose  of  deceiving  the  patient.  Half 
an  hour  afterwards,  while  at  play,  he  pinched  his  finger  in  a 
door,  when  the  anger  and  excitement  brought  on  an  attack  of 
suffocation  to  which  he  succumbed  in  a  few  minutes.  The  au- 
topsy revealed  a  slight  stricture  with  induration  of  the  vocal 
cords.  The  anatomical  lesion  which  was  already  troublesome 
to  his  breathing,  had  been  suddenly  complicated  by  a  spasm 
which  rendered  it  fatal. 

Polypi  of  the  Trachea. 

Gigon,  of  Angouleme,  reported  the  history  of  a  child  from 


SEQUELS  OF  TRACHEOTOMY.  609 

whom  the  canula  could  be  removed  at  the  end  of  fifteen  days, 
but  whose  breathing  was  incompletely  reestablished.  Attacks 
of  suffocation  came  on  and  necessitated  a  second  tracheotomy 
forty-five  days  after  the  first.  There  were  then  perceived  at 
the  level  of  the  tracheal  cicatrix,  some  rounded,  reddish,  mov- 
able bodies,  the  size  of  peas,  whose  mass  diminished  the  cali- 
bre of  the  passage.  They  were  excised.  The  canula  could 
be  removed  the  third  day,  and  the  recovery  was  permanent. 

Bergeron  presented  to  the  Societe  niedicale  des  hbpitaux  the 
history  of  a  child  who,  after  several  unsuccessful  attempts  at 
removal  of  the  canula,  died  of  pneumonia  the  twenty-third  day 
after  the  operation.  The  autopsy  brought  to  light,  on  the  an- 
terior aspect  and  just  at  the  lower  extremity  of  the  larynx,  at 
about  I  centimetre  above  the  incision  in  the  trachea,  a  small 
polypus  on  a  pedicle.  It  was  recognized  that  this  polypus  was 
the  obstacle  which  prevented  the  removal  of  the  canula  and 
which  must  have  been  the  cause  of  several  attacks  of  suffoca- 
tion mistaken  for  attacks  ot  laryngismus  stridulus,  which  had 
twice  recurred  several  months  before  the  invasion  of  croup. 

This  eminent  physician  insists  upon  the  difficulty  of  diag- 
nosis, and  shows  that  little  confidence  can  be  placed  in  the  use 
of  the  laryngoscope  in  young  children. 

Krishaber's  patient  has  been  the  subject  of  a  thorough  dis- 
cussion from  the  standpoint  of  diagnosis.  The  conclusion  is 
that  the  polypus  had  existed  before  the  tracheotomy,  and  that 
he  had  not  had  croup.  Krishaber  based  this  opinion  upon  the 
existence  of  a  jerky  and  dry  cough  dating  from  far  back,  upon 
the  absence  of  false  membranes,  and  upon  the  very  clear 
intermittence  of  the  symptoms  during  the  three  months  which 
followed  tracheotomy,  an  intermittence  which  is  found  among 
patients  affected  with  polypi  of  the  air-passages. 

Of  the  two  patients  cited  by  Bouchut,  one  did  not  present  a 
single  symptom  peculiar  to  polypus,  and  the  autopsy  disclosed 
it  by  chance.  The  other  remained  for  six  years  with  his 
canula,  for  at  each  attempted  removal  an  attack  of  suffocation 
supervened.  The  canula,  moreover,  did  not  serve  at  all  for 
the  passage  of  air,  for  it  was  very  small,  the  size  of  a  goose 
quill,  and  it  could  even  be  stopped  with  a  cork  without  causing 
the  patient  trouble  in  breathing  or  in  speaking  aloud  clearly 


OlO  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

and  distinctly.  This  instrnment  had,  apparently,  no  other  use 
than  to  depress  a  tumor  which  without  that  compression  be 
came  elevated  and  took  a  position  in  the  trachea  which  ob- 
structed the  air-passage.  Exploratory  manoeuvres  had  to  be 
quickly  interrupted  every  time,  because  of  the  imminence  of 
suffocation. 

Calvet,  of  Castres,  operated  in  1869  upon  a  child  8  years 
old  affected  with  croup.  False  membranes  were  expelled  after 
the  operation.  The  removal  of  the  canula  took  place  the 
eighth  day,  and  six  days  afterward  the  wound  was  covered 
with  a  scab.  One  month  after  complete  recovery  the  little 
girl  was  taken,  while  asleep,  with  a  snoring  which  increased 
day  by  day,  and  became  so  loud  that  persons  sleeping  in  the 
adjoining  rooms  were  discommoded  by  it.  Little  by  little  res- 
piration became  difficult  and  wheezing  during  the  day.  One 
night  (about  2  o'clock  in  the  morning)  the  child  awoke  in  a 
start,  called  her  father  while  arising  in  her  bed,  in  great  ter- 
ror, and  fell  back  dead  upon  her  couch.  Tracheotomy  which 
was  proposed  when  the  symptoms  assumed  a  serious  character, 
had  been  refused  by  the  parents. 

No  autopsy  could  be  obtained.  'm 

It  is  difficult  to  explain  these  symptoms   ohterwise   than  by  I 

the  development  of  a  tumor  at  the  level  of  the  cicatrix  or  in  its  ji 

vicinity. 

Dr.  Jacobi,  of  New  York,  reports  that  in  four  cases  the  abla- 
tion of  the  canula   was  rendered   impossible   by  polypoid    ex-  , 
crescences,  sometimes  numerous,  the  size  of  which  varied  from     '^H 
that  of  the  head  of  a  pin  to  that  of  a  pea  and  larger,  implanted          |lr 
on  the  border  of  the  tracheal  incision  and  coming,  in  one  case,  i 
from  the  inferior   portion  of  the   larynx.      Numerous   applica- 
tions of  nitrate  of  silver  and  sulphate    of   iron    brought  about 
their  destruction.     Their  disappearance  at   once   removed  the 
obstacles  to  the  final  withdrawal  of  the  canula.                                        j 

Prof.  Steiner  mentions  voluminous  vegetations  arising  from 
the  edge  of  the  tracheal  wound  and  forming  a  tongue-like  pro- 
tuberance in  the  air-passage.  I  observed  in  1871  a  similar 
case  of  which  the  following  is  the  resume: 


SEQUELAE  OF  TRACHEOTOMY.  6ll 

Ren6  B ,  aged  3  years,  entered  Saint  Eugenie's  Hospital,  ward  S'.   Benjamin 

No.  14,  on  account  of  croup  in  its  third  stage.  Tiacheotomy  was  immediately  per- 
formed. As  the  incision  was  too  small  it  was  enlarged  with  the  bistoury,  and  there- 
from an  abundant  hemorrhage  resulted.  The  patient,  however,  rallied.  '1  he  phy- 
sician who  had  attended  the  child  before  his  entry  into  the  hospital  called  to  see  him, 
and  claimed  to  have  seen  upon  his  tonsils  false  membranes  which  he  had  cauterized 
with  nitrate  of  si'ver.  I  will  add,  to  thoroughly  establish  the  diphtheritic  character 
of  the  disease,  that  duiing  the  hrst  few  days  after  the  operation  fragments  of  false 
membrane  were  expelled  through  the  wound  and  through  the  canula.  Several  pieces 
of  cartilaginous  debris  belonging  to  the  rings  of  the  trachea  and  doubtless  detached 
by  the  second  cut  of  the  bistoury,  were  also  expelled  with  the  sputa. 

At  the  expiration  of  a  month  the  canul  1  could  not  yet  be  removed,  for  voluminous 
vegetations  were  perceived  which  appeared  to  come  from  the  trachea,  and  obliterated 
the  wound  as  soon  as  the  canula  was  taken  away.  These  productions  had  the  most 
complete  resemblance  to  large  masses  of  granulations.  Cauterization  with  nitrate  of 
silver  brought  temporaiy  relief;  the  patient  could  remain  two  or  three  hours  without 
the  canula  before  the  granulations  reappeared  and  suffocation  returned.  Everything 
tended  to  the  belief  that  the  laiynx  was  free,  for  the  voice  was  clear  and  the  ai  cir- 
culated freely  when  the  wound  was  closed  with  the  finger,  but  suffocation  soon  re- 
turned. Then  violent  retraction  [tirage)  was  produced,  and  attacks  of  coughing, 
during  which  the  tumor  was  driven  into  the  wound  of  the  soft  parts  with  such  a  force 
that  it  was  ]iossible  to  seize  it  with  forceps  and  tear  it  off.  When  the  canula  was  in 
place,  respiration  was  always  easy,  even  when  the  instrument  was  closed  with  the 
ball  of  the  linger.  The  vegetations  certainly  did  not  arise  from  the  soft  parts,  for 
they  were  seen  to  emerge  from  ibe  trachea,  and  they  appeared  to  be  planted  upon 
its  edges.  It  seemed  that  the  canula  when  put  in  place,  compressed  them,  which  ex- 
plained why  they  did  not  appear  in  the  first  few  moments  following  its  removal  and 
why  the  breathing  was  then  easily  carried  on,  becoming  difficult  and  even  impossible 
when  on  resuming  their  volume  they  projected  into  the  trachea. 

Removal,  combined  with  cauterization  with  nitrate  of  silver  an  1  with  chromic  acid, 
was  ineffectual.  After  each  operation  there  was  a  respite  of  several  days  followed 
inevitably  by  a  relapse.  At  the  expiration  of  seven  months  the  child  left  the  hospital 
without  being  cured,  or  being  able  to  go  without  the  canula.  His  mother  brought 
him  to  me  at  my  office  three  months  after  his  departure.  His  condition  was  the 
same,  but  the  wound  was  considerably  contracted  and  it  had  become  very  difficult  to 
introduce  the  canula,  for,  during  the  short  time  it  was  withdrawn  the  orifice  became 
unusually  contracted,  and  it  was  necessary  to  have  recourse  every  time  to  the  dila- 
ting canula  of  Bourdidat.  I  recommenced  the  treatment  by  removal  and  cauterization 
combined.  I  had  a  pair  of  forceps  made  with  spoon  shaped  jaws  with  cutting  edges 
which  easily  enabled  the  seizure  of  the  tumor  and  cutting  of  it  off.  I  several  times 
removed  tumors  the  size  of  a  large  pea,  soft,  friable,  red  and  like  granulations  in 
evety  respect.  Having  proved  that  breathing  was  carried  on  easily  when  the  canula 
was  closed  with  a  stopper,  I  had  the  canula  closed  permanently.  By  fullowing  this 
course  persistently,  the  child  was  able  to  remain  some  days  without  a  canula,  but  it 
could  never  be  jjermanently  removed. 

I  regret  that  I  have  lost  sight  of  this  interesting  patient  and  that  I  have  remained 
without  information  as  to  what  became  of  him. 


6l2  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

There  is  every  reason  to  suppose  that  the  symptoms  were 
due  to  the  production  of  a  polypus  on  the  surface  of  the  tra- 
chea about  the  wound.  There  was  nothing  to  give  rise  to  the 
supposition  that  the  tumor  had   existed   before  the  operation. 

This  case  presents  a  remarkable  likeness  to  one  of  those 
which  Bouchut  cited,  for  the  compres.-^ing  action  of  the  canula 
was  exactly  reproduced  in  it. 


[D.  E.  Beaty,  Jr.,  aged  3  years  and  i  month,  operated  for  croup,  March  22,  1877. 
The  details  have  been  published  and  need  not  be  repeated  here.  The  tube  was  per- 
manently removed  after  the  operation  on  the  sixth  day.  On  the  eighteenth  day  I 
find  the  following  note :  "Wound  nearly  closed  ;  air  escapes  through  the  wound  only 
on  coughing;  speaks  aloud  with  little  effort;  appetite  good."  Saw  the  case  on  May 
6.  Inspiration  was  difficult,  especially  so  when  sleeping  or  resting,  and  in  the  latter 
part  of  the  day  and  at  night.  This  condition  had  showed  itself  for  some  days,  but 
when  he  was  thoroughly  awake  and  playing,  i  attracted  but  little  attention  and  pro- 
duced but  little  embarrassment.  On  May  7  he  was  quite  bad.  Prescribed  for  him, 
but  did  not  see  him  again  until  May  10,  considerable  relief  having  been  obtained. 
From  this  time  the  obstruction  became  more  marked,  and  inspiration  more  difficnlt 
when  droiusy  or  7vhen  sleepini^.  Remedies  produced  little  or  no  effect.  The  ex- 
piration seemed  to  be  but  slightly  affected  ;  no  paroxysms  occurred  ;  the  condiiion 
grew  slowly  worse.  At  times  the  child  being  weary  and  sleepy  from  the  long-con- 
tinued and  laborious  efforts  at  inspiration,  there  would  be  several  fruitless  attempts 
at  inspiration,  repeated  until  he  would  arouse  himself  and  take  a  deep,  forced  in- 
spiration. Even  this  condition  grew  worse,  and  I  presented  the  only  remedy  which 
offered  any  hope,  viz..  tracheotomy.  I  regarded  it,  at  the  time,  as  paralysis  of  the 
muscles  of  the  glottis,  the  dilators  in  particular,  or,  at  least  a  loss  of  balance  (syn- 
ergy, correlation)  between  the  dilators  and  the  contractors,  possibly  spasm  of  the 
latter,  and  expected  immediate  relief  by  opening  the  trachea;  and  I  did  not  intend 
to  let  the  child  die  without  the  operation,  unless  opposed  or  over-r  ded. 

Dr.  J.  L.  White,  of  Bloomington,  111.,  having  been  telej^raphed,  was  in  consulta- 
tion, and  fully  concurred  in  the  necessity  of  the  operation,  which,  at  il  a.  m,,  I  pro- 
ceeded to  ■^e.xioxxa.,  Jifty-on  e  days  after  the  first  operation.  In  the  latter  part  of  May 
the  respiration  seemed  to  be  entirely  clear,  with  the  tube  in.  June  20 — "  Cannot 
sleep  with  the  tube  out  it  the  opening  in  the  trachea  is  entirely  covered  and  closed. 
The  same  difficulty  exists widi  inspiration  as  formerly."  In  July  I  used  electricity, 
and  stimulating  applications  to  the  larynx.  On  November  2  I  s^layed  with  him  till 
midnight,  leaving  the  tube  out  all  night.  There  was  no  special  trouble  in  respira- 
tion. The  parents  had  not  expected  to  leave  the  tube  out  permanently,  fearing  a  re- 
turn of  the  former  trouble,  and  the  next  day  I  found  considerable  difficulty  in  rein- 
troducing it.     Some  weeks  later  I  made  the  trial  again,  remaining  with  the  patient 


SEQUELS  OF  TRACHEOTOMY.  613 

all  night  About  midnight  the  difficulty  of  inspiration  became  so  great  as  to  neces- 
sitate the  re-introduction  of  the  tube.  Respiration  afterwards  has  been  carried  on 
with  the  fenestrated  tube  in,  and  about  as  well  when  it  was  closed  as  when  open.  The 
father  had  a  shorter  tube  made,  which  the  boy.  now  nearly  12  years  ohl,  has  contin- 
ued to  wear.  I  am  now  decidedly  of  the  opinion  th  it  the  case  was  one  of  polypoid 
or  exuberant  granulations  (which,  late  in  the  observation  of  the  case  I  attempted  to 
remove),  and  connected  with  that,  a  spasmodic  condition  of  the  parts.  He  became 
greatly  attached  to  his  tube  and  seemed  to  be  afraid  to  be  without  it.  He  still  wears 
the  tube — now  over  eight  years. 

I>r.  R.  W.  Parker,  of  London,  gives,  in  his  work  on  tracheotomy,  four  illustrations 
of  I lapillomata  and  polypoid  granulations  of  the  larynx  and  trachea,  preventing  the 
permanent  removal  of  the  tube. 


The  following  case  with  illustration  is  given  in  abstract  by  my  friend   Prof.    Isaac 
N.  Himes,  of  Cleveland,  O. 


Eddy  Biittner,  aged  4  years.  Diphtheria.  Saw  the  patient  in  consultation  in  De- 
cember, 1883.  Membrane  was  developed  on  both  tonsils  and  on  the  pillars.  At- 
tended him  for  five  days  during  which  time  his  breathing  and  cough  were  croupy. 
On  the  filth  day  of  the  consultation  he  began  to  show  signs  of  asphyxia.  During 
the  preparation  for  operation  asphyxia  increased,  producing  unconsciousness.  Re- 
traction of  the  chest  walls  was  well  marked.     Death  seemed  to  be  imminent. 

The  operation  was  performed  without  difficulty. 

The  cricoid  cartilage  and  the  crico-thyroid  membrane  were  divided  making  an 
opening  of  about  ^/i  of  an  inch  long.  No  tube  was  used.  A  heavy  plaited  surgical 
silk  thread  was  passed  through  the  end  of  the  cricoid  cartilage  on  each  side.  This 
was  passed  well  through  the  tissues,  but  not  through  the  skin,  but  was  allowed  to 
ride  upon  it.  Tapes  were  attached  to  these  cords  and  tied  behind,  encircling  the 
neck.  After  the  operation  the  atomizer  was  used  occasionally  during  the  night 
with  lime-water  spray.  Sponges  wrung  out  of  hot  water  were  allowed  to  rest  over 
the  orifice,  and  for  some  days  these  were  removed  every  fifteen  minutes.  Salt  water 
was  used  as  often  as  the  trachea  showed  dryness,  being  thrown  into  the  opening  and 
down  towards  the  lungs  by  means  of  a  small  rubber  syringe.  The  patient  was  fed 
on  beef  extract  and  milk.  In  swallowing,  some  of  the  milk  would  appear  at  the 
opening  in  the  trachea.  Thirteen  days  after  the  operation  the  wound  was  almost 
healed ;  he  could  then  make  a  vocal  sound.  Pulse  105  ;  respiration  25  in  the  minute. 
On  the  twenty-second  day  after  the  operation  he  was  sitting  up  eating  his  dinner 
and  he  was  beginning  to  articulate  very  well.  Forty-one  days  after  the  operation  he 
could  talk  plainly.  At  night,  however,  he  seemed  to  be  croupy  and  to  breathe  with 
difficulty.  Nearly  two  months  after  the  operation  the  doctor  was  called  to  see  him 
again.  "  Inspiration  was  made  with  tolerable  freedom,  but  the  breath  after  inspi- 
ration seemed  to  be  held  and  slowly  expired  with  a  cooing  sound  when  listened  to 
with  the  stethoscope."  The  breathing  had  been  worse  during  the  night.  There  was 
no  willingness  to  submit  to  any   operative  treatment.     About  thirty-six  hours  late 


6i4 


DIPHTHERIA,    CKOUP    AND    TRACHEOTOMY. 


Dr.  Sykora  was  called  to  see  him  in  the  mornin  ,   when  the  patient   suddenly  died, 
apparently  trom  spasm  of  riie  glottis. 


/ 


E^pi^lollis, 


/The  specimen  X9 

v\  /  ^ofn  ali}ds  poinl- 

^\      /  /^corjiu  of 


^  "^T     Cifisoii  aarlilaqe- 


Polypoid ,  or 
jranulalion  qnWlk 


Polypoid  ^rowvlh  Wilkin  ihe.  larynx^afterharyn^o^aoheolomy  in  a  alild 
foUT  years  olc',. 


Fig.  35. 


Posf  mortem  examination  was  reluctantly  permitted.     The  cicatrix  of  the  original 
incis.on  was  very  small,  scarcely  noticeable,  and  the  skin  was   movable   over   the 
deeper  structures.     "  Within  the  lumen  of  the  larynx  and  the  trachea  at  the   spot 
/ 


SEQUELAE  OF  TRACHEOTOMY.  615 

where  the  wound  had  been  made,  at  the  crico-thyroid  space,  there  was  a  small 
polyp-like  structure  about  the  size  of  a  soup  bean,  attached  by  a  small  fibrous  ped- 
icle. This  structure  had  developed  in  the  process  of  healing  of  the  wound.  When 
the  glottis  was  open  in  inspiration  it  did  not  present  a  great  obstruction  to  the  en- 
tering air,  but  in  the  relaxation  of  the  glottis  in  expiration,  when  the  lumen  of  the 
larynx,  small  and  soft  as  this  organ  is  at  this  age,  was  diminished,  this  growth,  which 
in  the  expiration  was  moved  upward  towards  the  narrow  chink  of  the  relaxed  glottis, 
produced  greater  obstruction  At  the  time  of  death  it  is  probable  that  this  growth, 
acting  like  a  foreign  body,  with  the  addition  of  some  increased  irritability,  produced 
spasm  of  the  glottis  and  the  sudden  fatal  termination.  The  lungs  were  distended 
with  air  and  filled  with  blood,  but  not  dark.  The  right  side  of  the  heart  was  com- 
pletely relaxed  and  empty  of  blood  ;  the  left  side  was  in  a  state  of  firm  contraction 
and  also  empty."] 

These  instances,  small  in  number,  but  significant,  show  that 
polypi  of  the  trachea  n:ay  manifest  themselves  either  before 
or  after  the  removal  of  the  canula  ;  [or  when  no  canula  has 
been  used.] 

The  former  oblige  the  patient  to  continue  this  artificial 
mode  of  respiation.  Every  time  the  attempt  is  made  to  do 
without  it,  respiration  becomes  gradually  or  rapidly  difficult, 
a  violent  cough  is  produced,  and  suffocation  is  imminent. 
When  the  tumor  is  on  a  pedicle  and  floating,  the  cough  pro- 
jects it  through  the  wound,  but  during  inspiration  it  reenters 
the  trachea.  Those  which  are  somewhat  large  and  attached 
by  an  elongated  pedicle,  project  as  far  as  the  external  orifice 
of  the  wound,  but  the  majority  scarcely  pass  the  orifice  of  the 
trachea.  On  separating  the  lips  of  the  wound,  a  small  red, 
rounded  body  is  perceived  which  in  every  respect  resembles  a 
mass  of  granulations.  Its  removal  is  always  followed  by  re- 
lief. While  the  canula  is  in  the  wound,  breathing  goes  on 
easily,  however  narrow  be  the  canula,  and  even  when  it  is 
closed.  The  instrument  has  a  double  action.  It  depresses 
the  polypus  which  rises  up,  and  resumes  its  position  in  the 
trachea  as  soon  as  the  pressure  ceases  to  be  maintained,  while 
it  also  compresses  it  and  flattens  it  to  that  degree  that  when 
the  canula  is  removed  it  often  happens  that  respiration  remains 
perfectly  free  for  a  certain  time,  which  the  tumor  needs  in 
order  to  resume  its  volume. 

When  the  foreign  body  is  formed  after  the  wound  has  closed 


6l6  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

and  cicatrized,  respiration  does  not  return  completely  to  its 
former  condition,  while  in  other  cases  it  remains  easy  for  a 
certain  time,  a  month  for  example.      (Calvet)  [and  H.  Z.  Gill.] 

The  beginning  comes  on  insensibly.  At  first  there  are 
slight  symptoms,  limited  to  a  moderate  snoring  during  sleep, 
then  progressive  augmentation,  laryngo-tracheal  wheezing, 
nocturnal  at  first,  then  diurnal ;  and,  finally,  attacks  of  suffoca- 
tion, more  and  more  intense,  becoming  fatal  if  surgical  aid 
does  not  promptly  combat  them,  while  the  first  one  may  be 
fatal  (Calvet).  They  occur  suddenly,  in  the  middle  of  the 
night  or  oftener,  as  the  result  of  excitement,  such  as  fear  or 
anger.  After  the  attack,  matters  return  completely  to  their 
usual  order.  The  remission,  however,  may  be  incomplete,  and 
some  respiratory  troubles  may  persist  with  an  intensity  corre- 
sponding to  the  size  of  the  tumor,  such  as  snoring,  whistling, 
wheezing  and  hoarseness  of  voice. 

The  course  of  these  symptoms,  however  continuous  it  may 
be,  simulates  intermittence.  Two  factors,  indeed,  are  neces- 
sary to  the  production  of  grave  troubles.  The  first  is  irritation 
of  the  mucous  membrane  caused  by  a  cold  or  by  the  contact 
of  the  tumor  with  a  foreign  body ;  the  second  is  spasm  of 
the  glottis  aroused  by  mental  emotions  and  by  the  inflamma- 
tion itself.  The  structure  of  these  vegetations  does  not  war- 
rant the  thought  that  mental  impressions  provoke  the  attack 
by  developing  the  tumor  by  producing  a  rapid  vascular  tur- 
gescence,  for  they  are  not  erectile  in  character.  Spasm  of 
the  glottis  is  the  only  tenable  hypothesis.  Diphtheritic  in- 
flammation, or  irritation  caused  by  the  presence  of  the  canula, 
is  their  probable  cause.  These  productions  may  be  formed 
about  the  point  where  the  canula  passes,  just  as  large  excres- 
cences are  developed  about  drainage  tubes,  setons,  etc. 

The  diagnosis  is  often  difficult.  Certain  polypi  are  over- 
looked and  are  recognized  only  at  the  autopsy.  This  singular 
toleration  of  the  trachea  is  probably  limited,  and  a  time  would 
have  arrived,  had  life  continued,  when  symptoms  would  have 
been  rapidly  produced. 

Disorders  like  those  which  polypus  causes,   have  sometimes 


SEQUELiE  OF  TRACHEOTOMY.  617 

as  their  only  origin,  spasm  of  the  glottis.  The  diagnosis  is 
very  difficult  if  the  attack  of  suffocation  be  regarded  as  the 
principal  symptom,  for  there  is  nothing  to  prove  that  the  at- 
tack was  produced  by  spasm  rather  than  by  polypus.  It  may 
appear  superfluous  at  first  to  differentiate  polypus  of  the  tra- 
chea from  the  neurotic  spasm  of  the  glottis  which  is  observed 
in  very  young  children  or  during  the  course  of  whooping- 
cough,  but  when  we  examine  the  course  of  croup  after  opera- 
tion, we  recognize  that  one  of  the  greatest  obstacles  to  the  re- 
moval of  the  canula  is  this  very  spasm  of  the  glottis.  The  dis- 
tinction has,  therefore,  its  practical  side. 

Spasm  pertains  especially  to  excitable  children  who  dread 
the  removal  of  the  canula  and  are  persuaded  that  they  cannot 
breathe  without  its  aid.  This  trouble,  which  is  entirely  emo- 
tional, ceases  under  the  influence  of  mental  treatment.  The 
tracheal  polypus,  even  when  it  does  not  project  into  the  wound, 
behaves  very  differently,  and  moral  measures  and  patience  are 
not  enough  to  overcome  it. 

When  dyspnoeic  symptoms  arise  after  the  cicatrization  of 
the  wound,  their  commencing  with  snoring  and  their  gradual 
increase  mark  them  as  dependent  upon  polypus.  The  integ- 
rity of  the  voice  distinguishes  tracheal  from  laryngeal  polypus, 
when  a  layngoscopic  examination  is  impracticable.  It  may  be 
useful,  finally,  when  the  existence  of  a  polypus  is  admitted  to 
know  whether  it  came  before  or  after  the  tracheotomy.  The 
verification  of  a  dry  and  jerky  cough  for  a  long  time  before 
the  operation,  intermittence  of  the  symptoms,  and  the  fact 
that  no  false  membrane  at  all  has  been  perceived,  give  a  strong 
presumption  in  favor  of  the  pre-existence  of  polypus. 

The  prognosis  is  grave.  Polypi  which  have  appeared  after 
the  cicatrization  of  the  wound,  have  brought  about  death  or 
the  necessity  of  a  second  tracheotomy.  In  these  conditions  a 
cure  may  be  obtained,  as  Gigon's  case  proves.  Those  which 
appear  early  retard  or  prevent  the  removal  of  the  canula.  In 
these  cases  cure  is  not  impossible. 

Treatment. — Polypi  which  develop  while  the  wound  is  still 
open  should  be  followed  up  by  removal  and  cauterization  com- 
bined. 


6l8  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

It  is  not  always  easy  to  grasp  these  excrescences,  for  they 
are  deep  down  and  often  do  not  project  into  the  wound  except 
during  efforts  at  coughing,  and  in  order  to  seize  them  we  must 
hold  the  forceps  open  in  the  wound,  make  the  patient  cough 
and  close  the  instrument  quickly  at  the  instant  when  the  tu- 
mor appears.  Their  slippery  surface  allows  them  often  to  es- 
cape from  ordinary  forceps,  and  their  friability  is  the  reason 
why  only  small  pieces  can  be  caught  at  a  time.  I  have  facili- 
tated this  manoeuvre  by  having  forceps  made  with  jaws  broad- 
ened, rounded  and  hollowed  out  like  a  spoon,  and  at  the  same 
time  having  cutting  edges.  This  arrangment  allows  a  larger 
portion  of  the  polypus  to  be  seized  and  cut  off  at  the  same 
time. 

Cauterization  with  nitrate  of  silver  or  with  chromic  acid 
should  immediately  follow  the  removal.  Caustics  running  into 
the  trachea  should  be  avoided.  For  this  purpose  care  should 
be  taken  in  the  first  instance  to  immediately  touch  the  cauter- 
ized surfaces  with  a  pencil  dipped  in  a  saturated  solution  of 
chloride  of  sodium. 

When  the  polypus  develops  after  the  occlusion  of  the 
wound,  a  second  tracheotomy  is  imperatively  indicated  as  soon 
as  snoring  or  whistling  during  respiration,  or,  with  much 
greater  reason,  when  attacks  of  suffocation  shall  have  created 
suspicion  as  to  the  nature  of  the  disease.  It  is  better  to  oper- 
ate than  to  await  these  attacks,  for  the  first  one  may  prove 
fatal.  After  the  trachea  has  been  opened  we  manage,  as  be- 
fore, if  the  polypus  projects,  which  feature  may  be  wanting. 
The  patient  must  then  retain  the  canula  until  cured.  When 
the  simple  means  which  have  just  been  indicated  are  not 
enough  to  destroy  the  polypi,  we  are  often  obliged  to  have 
recourse  to  operations  which  are  employed  in  laryngoscopy 
and  whose  complete  description  is  found  in  special  treatises 

Tracheal  Fistula. 

This  form  of  lesion  is  extremely  rare  in  the  absence  of  pol- 
ypus or  of  stricture.       I  know  of  but  two  cases,  one  cited  by 


SEQUELiE  OF  TRACHEOTOMY.  619 

Trousseau  and  the  Other  by  Dujardin,  of  Lille.  These  authors 
do  not  inform  us  by  what  cause  the  fistula  was  produced.  All 
that  we  know  is  that  Dujardin's  patient  wore  his  canula  for 
eight  months,  and  that  asphyxia  returned  at  every  attempt  to 
remove  it.  After  three  years  and  a  half  there  still  remained  a 
capillary  tracheal  fistula.  The  cause  of  that  persistence  re- 
mains unknown  to  us  in  these  two  cases.  The  most  probable 
hypothesis  is  that  of  a  loss  of  substance  suffered  by  the  tra- 
cheal rings  at  the  site  of  the  incision.  Ulceration  of  the  edges 
of  the  wound  or  multiple  incisions  made  during  the  operation 
are  the  conditions  which  best  explain  a  loss  of  substance  of 
that  kind. 

When  the  fistula  is  simply  linear,  and  when  it  is  not  accom- 
panied by  polypus  it  causes  no  disturbance  at  all  in  either  res- 
piration or  phonation.  If  larger  it  may  bring  about  certain 
troubles  in  the  emission  of  the  voice.  The  authors  just  cited 
do  not  tell  us  what  was  tried  to  remedy  this  condition.  Cau- 
terization of  the  track  with  a  red  hot  iron  would  perhaps  has- 
ten the  reunion  of  the  surfaces  by  augmenting  the  vitality  of 
the  tissues,  while  autoplasty  has  been  also  advised  by  several 
authors. 


CHAPTER   III. 


ACCIDENTS    REFERABLE   TO   THE  DIPHTHERITIC 

INFECTION. 

The  only  ones  which  deserve  mention  are  convulsions  and 
pulmonary  complications. 

I — Convulsions. 

I  have  spoken  of  those  which  manifest  themselves  at  the  be- 
ginning of  diphtheria.  There  are  others  much  more  interest- 
ing which  break  out  in  consequence  of  tracheotomy.  These 
are  the  most  common.  They  begin  a  short  time  after  the  op- 
eration, and  during  the  first  thirty-six  hours.  They  are  en- 
tirely included  within  these  limits  in  such  a  manner  as  to 
clearly  show  the  influence  of  the  traumatism.  Often  the  convul- 
sion is  single.  Its  duration  is  variable  and  it  may  last  for  five 
hours.  In  other  cases  they  recur  several  times  after  quite 
brief  intervals. 

Certain  ones  appear  at  a  stage  more  remote  from  the  opera- 
tion. They  are  not  produced,  like  the  preceding,  from  a 
traumatism,  but  from  the  action  of  an  accidental  cause,  as  an 
emotion  or  a  fright.  A  little  girl  of  2  years  had  a  convulsion 
nine  days  after  being  operated  on  for  croup  from  having  re- 
mained too  long  a  time  without  the  canula.  The  fright,  the 
agitation,  and  perhaps  a  slight  suffocation,  brought  on  the  ac- 
cident, which  passed  off,  however,  and  never  reappeared. 

Other  cases,  finally,  are  observed  at  a  still  later  stage,  but 
they  depend  upon  a  complication  or  upon  albuminuria.  They 
are  of  extreme  rarity. 

The  prognosis  varies  according  to  the  stage  and  the  case. 
Convulsions  which  come  on  at  the  beginning  are  without  grav- 

(6ao) 


4 


I 


SEQUELiE  OF  TRACHEOTOMY.  621 

ity.  Those  which  develop  under  the  influence  of  the  traumatism 
of  the  operation  are  always  fatal.  The  patient  is  carried  off 
in  one  of  the  convulsions  or  succumbs  a  few  hours  afterwards. 
As  to  those  which  come  on  later,  they  are  almost  always  of 
evil  augury  because  they  announce  that  a  complication  is  im- 
minent. If  the  patient  does  not  succumb  to  the  convulsion, 
he  has  many  chances  to  be  carried  off  by  the  recent  accident. 
An  exception  may  be  made  in  favor  of  those  which  are  due  to 
an  emotional  disturbance. 

II. — Pulmonary  Complications. 

These  depend,  for  the  most  part,  on  the  diphtheritic  infec- 
tion. This  fact  is  now  beyond  doubt,  and  I  have  already 
given  the  reasons  for  it.  The  opinion  which  considered  them 
as  the  exclusive  result  of  tracheotomy  has  justly  been  aban- 
doned. I  have  recognized,  however,  that  the  operation  might 
play  a  part  in  their  development  on  account  of  the  direct  in- 
troduction into  the  trachea  of  air  which  is  still  cold  and  dry. 
They  were  formerly  the  most  dreaded  of  the  causes  of  mor- 
tality. Their  influence  was  not  lessened  until  after  the  inven- 
tion of  the  cravat  by  which  Trousseau  restored  the  air  entering 
the  trachea,  to  physiological  conditions.  Though  much  more 
rare  than  formerly,  they  are  still  very  frequent,  and  should  be 
reckoned  among  the  accidents  which  follow  tracheotomy.  It 
only  remains  now  for  me  to  indicate  the  physiognomy  which 
they  present  in  those  who  have  undergone  the  operation.  The 
fever,  the  oppression  and  the  frequency  of  respiration,  have 
nothing  peculiar.  It  is  on  the  part  of  the  canula,  and  in  the 
expectoration  that  certain  special  phenomena  are  found. 

I  have  heretofore  examined  the  features  of  the  expectora- 
tion when  the  disease  progresses  without  hindrance  toward  re- 
covery. During  the  first  few  hours  which  follow  the  operation 
the  fluids  thrown  out  through  the  canula  are  tinged  with  blood 
and  the  intensity  and  duration  of  that  discoloration  are  depend- 
ent upon  the  quantity  of  blood  thrown  into  the  bronchi.  It 
the  loss  of  blood  continue  after  the  operation   and  it  penetrate 


622  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

into  the  pulmonary  cavity,  the  blood  is  thrown  out  through 
the  canula,  either  mixed  with  sputa  or  pure. 

Laudable  expectoration  is  formed,  after  the  disappearance 
of  the  blood,  by  mucus  which  is  transparent  and  tenaceous  or 
opaque  ;  in  the  latter  case  there  are  found  in  the  vessel  which 
receives  it,  thick,  rounded,  yellow  or  greenish  sputa,  lighter 
than  water. 

When  the  trachea  and  the  larger  bro?ichi  are  the  site  of  an 
intense  inflammation,  the  expectoration  ceases  to  be  mucous  ; 
it  diminishes  and  dries  up,  or  becomes  purulent,  oftener  sero- 
purulent,  and  sometimes  grumous,  and  of  a  yellow  color  which 
is  sometimes  bright  and  sometimes  verging  toward  gray.  It 
is  abundant.  Its  odor  is  unpleasant.  The  canula  is  noisy  and 
emits  a  gurgling  noise  which  is  audible  at  a  distance.  It  be- 
comes easily  obstructed,  respiration  is  embarrassed,  the  child 
coughs  frequently  and  each  attack  is  accompanied  by  redness 
of  the  face.  The  cloths  placed  before  the  canula  are  soiled  by 
the  matters  expectorated,  and  must  be  frequently  renewed. 

This  kind  of  expectoration  should  convey  a  grave  prognosis; 
if  the  child  coughs  vigorously  it  may  succeed  in  driving  off 
this  mucosity  ;  but  if  the  cough  is  feeble,  fluids  accumulate 
little  by  little  in  the  bronchi  and  give  rise  to  asphyxia. 

Repeated  cleaning  of  the  internal  canula  and  changing  of 
the  cloths  which  surround  the  neck  are  indispensable,  for  we 
can  conceive  the  inconvenience  which  would  result  from  con- 
tact with  the  skin  of  these  wet  bodies  rapidly  becoming  cold, 
and  which  are  charged  with  matters  whose  exhalations  cannot 
but  become  a  new  element  of  infection.  It  also  indicated  to 
sustain  the  general  condition,  in  order  to  give  the  patient 
the  strength  necessary  to  throw  off"  the  bronchial  fluids. 
Generous  wines  should  be  insisted  on,  or,  indeed,  rum  can  be 
given  in  quantities  of  from  30.  to- 40.  grammes  (15  to  io5)  a 
day  by  taking  care  to  give  not  more  than  ten  drops  at  a  time 
in  a  spoonful  of  milk. 

Pulmonary  inflammations  impress  other  modifications  upon 
the  expectoration.  When  they  come  on  in  a  subject  whose 
sputa  present  the  preceding  features,  no    important   change    is 


1 


1 


SEQUELS  OP^  TRACHEOTOMV.  623 

produced.  But  if  the  expectoration  has  been  satisfactory  at 
first,  it  is  seen  to  diminish  and  almost  cease  at  the  moment 
w'len  the  oppression  and  the  fever  appear.  The  canula  re- 
mains noisy,  but  all  bubbling  noise  vanishes  and  gives  place  to 
a  whistling  which  is  often  intense. 

Gangtene,  when  it  attacks  the  trachea  or  the  lung  gives  rise 
to  a  semi-fluid  expectoration,  of  a  grayish-brown  or  greenish 
color  and  exhaling  the  characteristic  odor  of  gangrene.  The 
canula  is  blackened,  whet  .er  the  wound  be  gangrenous  or  not; 
;ind  since  the  disengagement  of  septic  products  is  taking  place 
through  the  lungs,  the  metal  is  altered  throughout  its  whole 
surface,  even  parts  not  in  contact  with  the  wound,  and  as  the 
black  discoloration  of  the  lower  extremity  is  proof  of  ulcera- 
tion of  the  trachea,  so  the  production  of  sulphide  of  silver  over 
its  whole  surface  and  upon  those  portions  which  do  not  touch 
the  wound  is  a  sign  of  gangrene  of  the  lung. 

Hcsmorrhages. — If  the  blood,  after  having  ceased  at  the 
usual  epoch,  reappears  in  the  sputa  after  a  few  days,  recur- 
rence of  the  haemorrhage  may  be  feared,  especially  \{  it  be 
abundant  and  but  slightly  mixed  with  mucus.  But  if  it  be 
scarce  and  intimately  incorporated  with  the  sputa  so  as  to  give 
them  a  slightly  brown  discoloration,  there  are  many  probabili- 
ties in  favor  of  an  ulceration  of  the  trachea,  especially  if,  at  the 
same  time,  the  lower  extremity  of  the  canula  take  on  the  black 
color  which  it  assumes  in  case  of  gangrene  of  the  wound. 


CHAPTER    IV. 


CAUSES  WHICH  RETARD  THE  REMOVAL  OF  THE 

CANULA. 

The  tables  in  which  I  have  arranged  the  dates  of  removal  ol 
the  canula  in  a  large  number  of  cases  collected  in  France  and 
in  other  countries,  bear  witness  of  an  excessive  discrepancy  be- 
tween the  extreme  limits  which  are  actually  known.  Though 
the  canula  might  need  to  remain  in  the  wound  only  a  day,  it 
was,  in  one  case,  necessary  to  retain  it  there  for  203   days. 

Numerous  causes  are  responsible  for  these  variations.  The 
complications  of  croup,  the  accidents  during  or  following  tra- 
cheotomy, the  intensity  of  the  disease,  its  duration,  its  re- 
lapses, its  sequelse,  diphtheritic  paralysis  among  them,  are  in 
the  list.  There  are  patients,  and  they  are  the  most  numerous 
with  whom  there  is  no  material  lesion  to  account  for  the  delay. 
Nothing  can  be  assigned  except  a  spasmodic  condition  de- 
pending almost  always  upon  the  emotions  of  the  patient. 

The  morbid  conditions  which  postpone  the  removal  of  the 
canula  may,  therefore,  be  grouped  as  follows  : 

1st.  Duration  of  diphtheritic  intoxication. 

2d.   Lesions  of  the  respiratory  apparatus. 

3d.  Accidents  of  the  wound. 

4th.  Diphtheritic  paralysis. 

5th,   Spasmodic  or  emotional  conditions. 

I. — Duration  of  Diphtheria. 

This  disease  has  no    fixed  limits.     Its   evolution   often  ends 

in  a  few  days,  but  it  may  last  for  several  weeks.     Besides,  it  is 

subject  to  reappear,  and  it  is  not  rare   to   see    several   relapses 

succeed  one  another.     The  period  of  removal  of  the  canula   is 

influenced  by  these  variations  and  is   postponed   so   much  the 

(624) 


SEQUELiE  OF  RTACHEOTOMY.  625 

longer  as  the  tendency  of  the  economy  to  exude  the  false 
membrane  is  the  more  lasting,  while  relapses  also  postpone 
still  further.  In  fact,  as  long  as  this  disposition  exists,  the  lar- 
ynx partakes  of  it.  While  it  happens  that  the  false  mem- 
bi'anes  cease  to  be  produced  on  the  day  after  the  operation, 
they  are  also  encountered  at  still  later  epochs,  and  I  have 
cited  a  case  where  they  appeared  as  late  as  the  thirty-second 
day.  Between  these  two  extreme  points  there  are  numerous 
intermediate  ones ;  yet,  in  favorable  cases  the  duration  of  the 
evolution  of  false  membrane  hardly  exceeds  the  first  week. 
Production  which  is  prolonged  beyond  that  may  be  considered 
as  causing  delay  in  the  removal  of  the  canula.  The  rejection 
of  pseudo-membranous  debris  through  the  canula,  and  the  ex- 
istence of  false  membranes  at  divers  points  of  the  economy,  at 
the  same  time  that  the  larynx  is  impermeable,  constitute 
strong  presumption  in  favor  of  the  persistence  of  the  pseudo- 
membranous covering  of  the  walls  of  this  cavity.  The  only 
position  to  take,  in  such  a  case,  is  to  patiently  wait  till  the  pro- 
duction of  false  membrane  ceases.  Guersant  has  advised  a 
manoeuvre  which  he  designates  by  the  name  of  sweeping  the 
larynx ;  but  it  is,  to  say  the  least,  useless. 

II. — Lesions  of  the  Respiratory  Apparatus. 

1st. — Laryngeal  Lesion. 

{a)  Tumefaction  of  the  Laryngeal  Mucous  Membrane. — In  two 
patients,  who  could  not  go  without  their  canula  without  res- 
piration becoming  embarrassed  and  without  asphyxia  becom- 
ing menacing,  death  supervened  under  the  influence  of  a 
broncho-pneumonia.  The  autopsy  disclosed  that  the  mucous 
membrane  was  red  and  hypertrophied.  and  formed,  at  the  level 
of  the  inferior  vocal  cords,  salient,  non-oedematous  folds  which 
obstructed  the  glottis.  These  patients  had  thrown  off  false 
membranes,  and  no  laryngeal  accident  had  been  noted  before 
the  invasion  of  croup.  We  had,  therefore,  to  deal  not  with  an 
old  alteration,  but  rather  with  a   recent   lesion    resulting  from 


626  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

the  phlogosis  which  had  given  rise  to  the  exudation.  It 
is  this  tumefaction  which,  between  the  successive  attacks  of 
diphtheria  upon  the  larynx,  may  render  it  impermeable  to  air 
as  though  the    false  membranes  remained  permanently. 

{d)  Qidenia  of  the  Glottis. — In  several  patients  a  true  oedema 
of  the  glottis  has  constituted  the  obstacle  to  the  removal 
of  the  canula. 

{c)  Polypi. — There  exists  no  authentic  example  of  a  polypus 
which  has  grown  in  the  larynx  in  consequence  of  croup,  and 
has  furnished  the  symptoms  characteristic  of  laryngeal  tumors. 
Those  in  question  came  from  the  inferior  portion  of  the  larynx, 
and  fell  into  the  tracheal  incision  which  put  them,  as  regards 
symptoms  and  treatment,  under  the  same  head  of  tracheal 
polypi, 

{d)  Alterations  of  the  Muscles. — Lesions  of  the  laryngeal 
muscles,  and  especially  of  the  thyro -arytenoids,  are  very 
probably  of  great  causal  importance  in  the  delays  which  now 
occupy  us.  The  functions  of  the  larynx,  compromised  by  the 
paresis  of  the  muscles,  are  incompletely  performed.  Since 
these  muscular  alterations  are  not  rare,  it  is  legitimate,  when 
we  find  no  other  explanation,  to  attribute  to  them  the  attacks 
of  dyspnoea,  the  snoring  or  the  whistling  which  supervene  at 
the  moment  when  it  is  desired  to  remove  the  canula.  Laryn- 
goscopic  examination  would  be  of  great  use  in  supporting  or 
refuting  the  data  of  pathological  anatomy  ;  but  unfortunately 
it  is  of  extreme  difficulty  in  the  child.  [Other  causes  are  :  In- 
turned  cartilage  retained  in  position  by  inflammatory  products^ 
tendency  on  the  part  of  the  trachea  to  collapse. — Passavant^ 

Electrization  of  the  lar^-ngeal  region  through  the  skin,  or 
carried  directly  to  the  muscles  in  the  cavity  of  the  pharynx 
may  modify  their  nutrition  in  a  happy  manner,  and  regulate 
their  functions. 

{e)  Necrosis  of  tJie  Cartilages. — In  certain  cases  of  gangrene, 
mortification  has  reached  the  cartilages.  These  lesions,  in 
general  quite  considerable,  and  allied  to  a  profound  infection, 
have  always  been  fatal.  If,  as  an  exception,  a  cure  were  ob- 
tained, grave  disorders  might  be  present  which  would  certainly 
condemn  the  patient  to  retain  the  canula. 


SEQUELS.  OF  RTACHKOTOMV.  62/ 

2nd. — Tracheal  Lesions. 

Strictures  of  the  trachea  and  polypi  formed  about  the  wound 
are  powerful  causes  of  respiratory  troubles  which  oblige  the 
patient  to  retain  the  canula.  Their  history  has  already  been 
given. 

3rd. — Accidents  of  the  Wound.    Vegetations. 

When  the  wound  granulates  too  rapidly,  there  are  some- 
times formed  voluminous,  pedunculated  vegetations  which 
float  in  the  wound  similar  to  polypi.  Rouziez  Joly  cited  an 
interesting  case  of  this  kind.  The  excrescences,  which  must 
not  be  confounded  with  polypi  of  the  trachea,  are  attached  to 
the  superior  angle  of  the  wound,  and  float  into  its  track.  They 
have  the  form,  size  and  mobility  of  the  uvula.  Inspiration 
draws  them  into  the  trachea,  whence  comes  suffocation. 

Confusion  is  easy  between  these  vegetations  and  polypi  of 
the  trachea.  To  avoid  error  we  must  carefully  search  for  the 
point  of  insertion,  and  when  this  is  not  clearly  perceived,  every- 
thing leads  to  the  belief  that  the  tumor  comes  from  the  tra- 
chea. In  case  of  polypus  of  the  wound  removal  and  cauteri- 
zation immediately  terminate  all  the  symptoms,  while  in  that 
of  the  tracheal  origin,  the  impossibility  of  seizing  the  whole  of 
the  tumor  makes  the  relief  temporary  and  the  repetition  of 
treatment  necessary. 

4th. — Diphtheritic  Paralysis. 

The  laryngeal  muscles  may  become  enfeebled  in  their  ac- 
tion by  the  extension  of  the  paralysis  to  the'  nervous  trunks 
which  animate  them,  as  well  as  by  fatty,  degeneration.  Phy- 
siology teaches  that  section  or  paralysis  of  the  recurrent 
nerves  is  accompanied  by  a  complete  loss  of  voice  and  a  res- 
piratory disturbance  which  extends  to  asphyxia  in  young  ani- 
mals, by  reason  of  the  small  dimensions  of  the  inter-arytenoid 
portion  of  the  glottis  ;  this  narrowness,  in  fact,  deprives  the 
animal  of  the  safety  valve  which  that  portion  of  the  glottis  af- 


628 


DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 


fords  the  adult,  when  the  inter-ligamentous  portion  is  closed. 
But  the  occlusion  of  the  inter-ligamentous  portion  of  the 
glottis  is  the  direct  result  of  paralysis  of  the  posterior  crico-ary- 
tejioid  muscles,  the  sole  antagonists  of  the  rest  of  the  muscles 
of  the  larynx,  all  of  them  constrictors,  and  of  the  atmospheric 
pressure  which  tends  naturally  to  approximate  the  inferior 
vocal  cords  during  inspiration. 

These  physiological  data  fully  account  for  the  respiratory 
troubles  which  diphtheritic  paralysis  can  cause,  when,  after 
having  affected  the  sensitive  portion  of  the  pnemogastric  rep- 
resented by  the  superior  laryngeal,  this  causing  troubles  in 
deglutition  as  well  as  hoarseness  of  voice,  it  reaches  the  motor 
portion  represented  by  the  inferior  laryngeal.  By  virtue  of 
these  data,  when  a  tracheotomized  patient  who  is  affected  at 
the  same  time  with  diphtheritic  paralysis,  cannot  go  without 
his  canula,  the  laryngeal  symptoms  may  be  charged  to  the  ac- 
count of  paralysis,  when  neither  a  spasmodic  condition  nor  an 
organic  lesion  can  be  found  to  explain  them.  It  is  true  that 
it  is  not  common  for  diphtheritic  paralysis  to  act  in  this  way, 
for  it  more  readily  attacks  the  external  respiratory  muscles.  It 
plays,  however,  its  part,  together  with  stricture  and  with  pol- 
ypus, in  the  production  of  dyspnoea,  of  wheezing  and  of  hoarse- 
ness of  voice,  which  sometimes  persist  a  very  long  time  after 
the  cicatrization  of  the  wound. 

The  agents  employed  against  diphtheritic  paralysis,  viz., 
sulphate  of  strychnine  and  faradization  are  indicated  here. 
Potain  has  cited  a  child  in  this  difficult  situation,  who  was 
cured  by  electrization  at  one  sitting. 

5th. — Spasmodic  or  Emotional  Condition. 

The  patient  has  reached  a  condition  of  health  which  is  sat- 
isfactory in  every  respect ;  the  voice  is  clear,  the  air  passes 
freely  through  the  larynx,  no  lesion  can  be  suspected,  for  the 
false  membranes  are  no  longer  reproduced.  There  is  no  paral- 
ysis, the  general  condition  is  excellent,  and  yet  the  chlid  can- 
not remain  without  the  canula.       Accustomed  to   this   aid,  he 


SEQUELiE  OF  TRACHEOTOMY.  629 

refuses  to  go  without  it.  It  seems  to  him  that  respiration  is 
impossible  without  this  assistance,  and  he  refuses  to  try  his 
own  powers.  As  soon  as  the  canula  is  removed  he  becomes 
agitated,  struggles,  and  his  countenance  expresses  terror  or 
anger.  Respiration,  which  for  the  first  few  moments  went  on 
freely,  becomes  embarrassed,  and  suffocation  comes  on  without 
delay.  We  are  compelled  to  reinsert  the  instrument  as  quickly 
as  possible. 

In  other  cases,  very  well  described  by  Millard,  the  emotional 
influence,  though  acting  less  rapidly,  is  none  the  less  at  fault. 
The  fear  of  suffocation  is  extreme,  and  one  of  his  patients 
could  not  lose  sight  of  her  canula  for  an  instant,  and  was 
quickly  attacked  with  suffocation  upon  simply  the  threat, 
made  in  jest,  of  carrying  the  instrument  out  of  the  room.  It 
was  necessary  to  hang  it  about  her  neck.  I  saw  a  patient  in 
whom  the  complete  permeability  of  the  laiynx  authorized  at- 
tempts to  remove  the  canula.  Left  alone  for  a  few  moments 
one  day  when  he  was  without  a  canula,  he  was  taken  with 
such  fright  that  a  convulsion  came  upon  him,  which  lasted 
about  ten  minutes  and  from  which  there  was  much  trouble  in 
restoring  him. 

I  think  I  ought  to  reproduce  here  a  curious  observation  which  I  have  already  had 
occasion  to  cite.  It  relates  to  an  extremely  nervous  and  hysterical  little  girl  who 
could  not  be  separated  an  instant  from  her  canula  without  suffocating,  yet  this  did 
not  prevent  her  uttering  piercing  cries  and  exclaiming  in  a  loud  voice,  "My  canula  I 
my  canula!"  The  wound  contracted  with  very  great  energy  and  the  reintroduction 
of  the  canula  became  very  dillicult.  The  laryngoscope  demonstrated  the  integrity  of 
the  lar}'nx  and  there  was  no  gross  lesion  save  a  vegetation  which  was  removed  sev- 
eral times,  and  whose  disappearance  brought  only  a  slight  amelioration,  while  diph- 
theritic paralysis  had  ceased.  The  period  came  when  I  had  barely  time  to  make  the 
applications.  As  every  means  had  failed, antl  prolonged  observation  of  the  patient  had 
left  no  doubt  as  to  the  neurotic  character  of  these  symptoms,  it  was  resolved  to  deal 
sharply  with  the  pusillanimity  of  the  patient.  The  hundredth  day  after  the  operation 
in  ihe  morning,  I  withdrew  the  canula  and  remained  beside  the  child,  ready  to  perl- 
form  tracheotomy  again,  if  necessary,  but  resolved  to  triumph  over  the  fears  or  the 
ill  will  of  my  little  patient.  Success,  beyond  all  th  t  had  been  hoped  for,  crowned 
my  effort.  The  agitation  and  the  usual  contortions  were  not  wanting;  the  child 
asked  tor  her  canula,  cried  and  begged;  the  oppression  was  very  intense,  accompan- 
ied by  retraction  (lirage)  but  without  extending  to  asphyxia.  The  spasmodic  and 
really  hysterical  stamp  of  these  phenomena  became   more  manifest.     Each  inspira- 


630  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY, 

tion  was  accompanied  by  a  violent  sob  and  the  face  contracted  energetically,  espe- 
cially on  the  right  side.  After  a  short  time,  calm  returned  for  an  interval  which  varied 
from  a  few  minutes  to  an  hour,  and  then  the  agitation  was  resumed  with  the  same 
characteristics.  The  day  passed  in  this  way.  In  the  evening  as  the  child  was  very 
much  fatigued  and  the  oppression  was  increasing,  the  canula  was  replaced,  but  with 
extreme  difficulty.  It  was  necessary  to  dilate  the  wound  for  a  long  time,  and  then 
only  a  small  canula  could  be  made  to  enter ;.  008  ('/sin  )  in'place  of.  010  (^5  in,)  which 
she  had  habitually  worn.  The  experiment  was  continued  on  the  next  day  and  the  spas- 
modic movements  diminished  On  the  third  day  the  child  passed  the  night  without  the 
canula.  She  had  difficulty  in  going  to  sleej),  and  although  the  sleep  went  on  without 
interruptiou,  the  same  spasmodic  movements  of  the  inspiratory  and  facial  muscles 
were  noted.  The  wound,  however,  contracted  more  and  more  and  scarcely  admitted 
the  canula,  which,  as  a  precaution,  was  replaced  at  night  for  four  days,  and  finally 
withdrawn  the  hundred  and  twenty-sixth  day.  On  the  next  day  the  wound  had  coiri- 
pletely  closed.  The  spasmodic  movements  persisted  for  a  few  nights  more,  and  the 
child  was  able  to  leave  the  hospital  completely  cured. 

Another  patient  whose  history  Bergeron  has  kindly  allowed 
me  to  relate,  presented  similar  features.  He  could  not  remain 
without  the  canula  more  than  a  few  minutes,  yet  after  forty 
days  he  was  able  to  go  without  it  a  day  and  a  night,  but  on 
the  morrow  he  was  taken  with  such  an  attack  of  suffocation 
that  it  was  necessary  to  perform  tracheotomy  again.  After 
this  time  the  canula  could  not  be  left  out  over  a  quarter  of  an 
hour  every  day.  To  enable  him  to  speak,  the  use  of  a  canula 
fenestrated  on  its  upper  curve,  was  tried,  as  well  as  the  canule 
a  bonle  of  Luer.  He  went  on  in  that  way  until  the  hundred 
and  fitty-fourth  day,  when  he  died  of  a  broncho-pneumonia 
following  measles.  The  autopsy  did  not  reveal  any  lesion 
which  could  account  for  the  obstacle  to  respiration. 

It  is  difficult  not  to  refer  the  suffocation  in  these  children, 
especially  in  the  first  one,  to  the  emotional  condition  and  to 
spasm  of  the  larynx.  This  influence  is  still  more  striking  in 
Blachez's  patient  who  succumbed  to  a  laryngeal  spasm  pro- 
duced by  a  violent  fit  of  anger. 

Whooping  cough,  a  typical  spasmodic  disease,  prevents  in 
the  same  manner  the  removal  of  the  canula,  as  I  have  been 
able  to  assure  myself  with  regard  to  one  patient.  Another  was 
taken  at  each  dressing  with  an  attack  of  convulsive  cough 
which  occasioned  a  long  delay. 

It  has  been  said  that  the  emotional  condition  should  be  held 


SEQUEL.E  OF  TRACHEOTOMY.  63  I 

responsible  in  those  cases  only  where  the  obstacle  yielded 
after  a  quite  short  time.  According  to  Boeckel,  the  author  of 
that  theory,  prolonged  respiratory  troubles  correspond  with 
the  duration  of  the  sojourn  of  the  false  membranes  in  the  lar- 
ynx. They  proceed  from  a  lack  of  correlation  (synergy)  be- 
tween the  extrinsic  muscles  of  respiration  and  those  of  the 
larynx  proper.  These  latter  remaining  inactive  all  the  time 
the  patient  breathes  through  the  canula,  and  losing  little  by 
little  the  habit  of  acting  in  concert  with  the  extrinsic  group. 
The  facts  often  contradict  this  theory.  In  the  cases  of  delayed 
removal  which  I  have  encountered,  the  false  membranes  had 
not  remained  in  the  larynx  beyond  the  ordinary  period  ;  and 
still  further,  in  several  cases  where  their  reproduction  had  been 
very  active,  or  their  presence  had  been  verified  for  a  very  long- 
period  after  the  operation,  to  the  twenty- eight  day,  the  canula 
could  be  removed  on  the  next  day  or  the  day  after  that.  Two 
patients  only  retained  it  longer  ;  but  in  one  the  delay  could  be 
explained  by  the  fits  of  anger  to  which  he  gave  way  as  soon 
as  it  was  removed ;  and  in  the  other  an  attack  of  whooping 
cough  was  the  cause  of  the  delay. 

Another  patient,  it  is  true,  who  submitted  twice  to  tracheot- 
omy,presented  false  membranes  up  to  the  thirtieth  day  from  the 
first  tracheotomy,  which  was  also  the  thirty-fourth  day  from 
the  outset  of  the  disease,  and  the  fourteenth  from  the  second 
tracheotomy.  Complete  recovery  was  not  obtained  until  the 
expiration  of  three  months,  reckoning  from  the  beginning ; 
the  canula  could  not  be  removed  without  attacks  of  suffoca- 
tion. Would  it  not  be  more  easy  in  this  case  to  suppose  either 
a  persistent  obstruction  of  the  glottis  by  tumefaction  of  the 
mucous  membrane,  a  fact  whose  reality  I  have  shown,  or  an 
alteration  of  the  muscles  of  the  larynx,  rather  than  a  want  of 
synergy  of  the  respiratory  muscles. 

In  brief,  the  final  removal  of  the  canula  may  be  sometimes 
delayed  for  a  long  time  by  a  nervous  state  which  reveals 
itself  by  a  spasm  of  the  glottis  brought  on  by  the  least  emo- 
tion. That  condition  is  a  veritable  psychical  trouble  which 
recognizes  as  its  usual  cause  fear  of  the  removal  of  the  canula 


632  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

which  engenders  fits  of  anger  or  fright  quickly  followed  by 
laryngeal  spasm  and  by  suffocation.  Nervous,  excitable  chil- 
dren are  more  subject  to  this  than  others.  Other  affections  of 
spasmodic  character,  like  whooping  cough,  also  retard  recovery 
by  energetically  inviting  laryngeal  spasm. 

The  means  to  be  employed  in  such  cases  demand  much  tact. 
It  is  the  emotion,  in  fact,  which  must  be  attended  to.  The 
physician  and  those  who  assist  him  must  put  under  contribu- 
tion all  the  resources  which  their  imagination  and  their  knowl- 
edge of  the  character  of  the  child  furnish.  Mildness  and  pa- 
tience or  authority  and  intimidation,  may  be  employed  as 
needed.  Excellent  results  are  obtained  from  a  great  variety 
of  subterfuges  born  of  the  occasion,  which,  moreover,  often  sug 
gests  happy  expedients. 

Millard  reports  very  interesting  instances  which  I  have  al- 
ready cited  (see  page  629). 

I  have  seen  patients  become  reassured  provided  the  canula 
was  hung  in  full  view  at  the  head  of  their  bed.  But  there  are 
children  whom  these  means  will  not  persuade,  and  who  abso- 
lutely will  not  remain  without  the  canula.  The  larynx  should 
then  be  carefully  explored  while  the  edges  of  the  wound  are 
approximated  with  the  fingers,  or  the  canula  is  closed.  If  the 
larynx  be  not  free,  the  trial  should  be  repeated  at  intervals  of 
one  or  two  days,  but  if  it  be  clear,  let  the  child  struggle,  while 
you  are  ready,  canula  in  hand,  to  give  it  succor  in  case  of  real 
danger.  Millard  advises  not  to  push  the  experiment  far 
enough  to  allow  the  child  to  get  a  real  attack  of  suffocation, 
for  he  thinks  that  the  terror  which  would  follow  would  add 
another  difficulty  to  those  already  existing.  I  subscribe  fully 
to  this  precept  in  cases  where  the  outset  is  still  recent ;  but 
where  the  disease  is  of  long  standing,  we  only  succeed,  by  ob- 
serving it,  in  protracting  the  obstacle  and  in  prolonging  in- 
definitely an  abnormal  and  uncomfortable  condition.  With 
the  patients  whose  history  I  have  reported,  I  have  only  to  con- 
gratulate myself  on  having  hastened  its  termination. 

When  the  preceding  methods  have  failed,  it  will  be  found  of 
advantage  to  withdraw  the  canula  while  the  patient   is  asleep. 


SEQUELiE  OF  TRACHEOTOMY.  633 

This  expedient  which  requires  certain  precautions,  often  suc- 
ceeds very  well,  provided  the  child  is  not  waked  up  while 
doing  it.  The  attempt  has  been  made  to  obtain  the  same  re- 
sults by  means  of  various  modifications  in  the  canula.  I  will 
not  speak  of  those  which  are  fenestrated  on  their  convex  sur- 
face. While  they  allow  the  air  to  pass  through  the  larynx  and 
sometimes  permit  the  patient  to  speak,  they  are  of  no  other  use, 
for  they  are  retained  as  long  as  the  others.  Moreover, 
the  superior  orifice  is  often  plugged  by  the  mucus  or  by  folds 
of  swollen  mucous  membrane,  and  in  either  instance  the  patient 
is  deprived  of  speech. 

Laborde  contrived  very  short  canulae,  penetrating  so  slightly 
into  the  larynx  that  the  least  shake  would  displace  them  from 
it,  when  they  would  remain  in  the  wound  in  the  soft  parts, 
having  no  action  upon  respiration,  but  the  child  would  feel 
that  he  was  wearing  a  canula  and  would  be  at  ease.  This  mod- 
ification was  useful  in  one  case  reported,  but  its  employment 
is  difficult  to  extend  to  other  cases,  for  few  children  will  allow 
themselves  to  be  deceived  by  it. 


The  accompanying  cut — FiG.  36 — illustrates  a  tube  inv  ntjd  and  used  success- 
fully by  Dr.  Hendrix,  of  St.  Louis,  Mo.,  for  the  gradual  withdrawal  of  the  tube  in 
tracheotomy  in  these  complicated  cases. 

Blanchet,  of  Montet,  (AUier)  used  a  different  artifice,  but  of 
more  certain  effect.  Having  to  deal  with  a  very  excitable  lit- 
tle girl  who  very  much  feared  the  removal  of  the  canula,  he 
strove  for  a  month,  employing  without  success  the  most 
various  means,  when  he  conceived  the  idea  of  introducing 
every  morning  a  narrower  canula  than  the  former  one.  Suc- 
cess was  soon  attained,  and  after  tlie  fourth  day  the  last  canula, 


^34  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

which,  moreover,  was  no  longer  of  use,  was  removed  and  the 
child  did  not  notice  it.  [A  short  conical  "plug,"  just  long 
enough  to  reach  but  not  enter  into  the  trachea,  attached  to  the 
metal  collar  as  a  substitute  for  the  tube,  is  recommended  by 
R.  W.  Parker.] 

Catheterism  of  the  Glottis. 

Necessity,  in  making  the  history  of  croup  complete,  has  con- 
strained me  to  say  a  few  words  about  a  system  of  operation 
devised  and  recommended  by  Bouchut.  Attributing  a  baleful 
influence  to  tracheotomy,  this  author  endeavored  to  find  a 
method  capable  of  replacing  with  advantage  that  operation. 
The  idea  of  laryngeal  catheterism  had  occurred  to  several  au- 
thors at  a  period  already  remote.  Desault  had  succeeded  in 
leaving  catheters  in  the  larynx,  and  like  procedures  had  been 
recommended  by  Green,  Chapman  and  Loiseau.  Bouchut  in- 
vented straight,  cylindrical  ferrules  of  silver  .015  to  .02  (Ys  to 
^/s  in.)  in  length,  provided  at  their  upper  extremity  with  two 
flanges  .006  (7*  in.)  apart  and  pierced  with  an  eye  for  the  pas- 
sage of  a  silk  thread  for  the  purpose  of  holding  them  up  or  re- 
moving them  {retejiir  au  dehors). 

The  mouth  was  held  open  by  means  of  a  peculiar  wedge. 
The  index  finger  of  the  left  hand,  protected  by  a  metallic  ring, 
elevated  the  epiglottis.  The  right  hand  introduced  into  the 
larynx  a  male  catheter  of  variable  size,  upon  which  the  ferule 
was  guided  as  far  as  the  lower  portion  of  the  larynx,  in  such  a 
manner  that  the  upper  flange  was  placed  below  the  superior 
vocal  cord.  In  that  position  the  ferrule  held  itself  without  pre- 
venting the  play  of  the  epiglottis  or  of  the  arytenoid  cartilages. 
It  was  left  in  place  until  the  asphyxia  ceased. 

The  results  were  not  very  encouraging.  The  apparatus 
clogged  easily,  and  the  asphyxia  was  relieved  so  little  that  tra- 
cheotomy had  to  be  performed  ///  extremis,  where  the  ferrule 
had  proved  itself  powerless.  It  was,  moreover,  far  from  being 
exempt  from  danger.  The  experiments  of  Trousseau  and 
Bouley  upon  animals  disclosed  in  the  larynx,  after   forty-eight 


SEQUELAE  OF  TRACHEOTOMY.  635 

hours  of  catheterism,  grave  disorders,  such  as  ulceration  and 
destruction  of  the  mucous  membrane,  denudation  of  the  carti- 
lages, etc. 

Trousseau  and  Bouvier  presented  objections  [porterent  des 
coups)  to  catheterization  from  which  it  will  not  recover.  It 
was  abandoned  by  its  author  himself 

Intubation  of  the  Larynx.  • 

[The  recent  re-introduction  of  this  subject  to  the  notice  of  the 
profession  and  into  practice,  and  the  application  of  improved 
instruments  in  the  operation,  as  a  substitute  for  tracheotomy 
in  many  cases  of  laryngeal  obstruction,  are  due,  first,  to  Dr. 
Joseph  O'Dwyer,  physician  to  the  New  York  Foundling  Asy- 
lum :  and,  in  the  same  field,  to  Drs.  F.  E.  Waxham  and  E.  F. 
Ingals,  of  Chicago,  and  others  in  this  country. 

The  reports  of  cases  to  which  this  method,  as  now  practiced, 
has  been  applied,  are  becoming  too  numerous  and  too  impor- 
tant to  be  omitted  here.' 

Though  the  range  of  its  application,  as  a  substitute  for  tra- 
cheotomy, may  not  yet  be  established,  it  has  a  just  claim  to 
the  attention  of  the  profession,  and  seems  rapidly  to  be  gain- 
ing favor.  Its  exact  status,  as  to  the  cases  in  which  it  should, 
as  a  procedure,  be  preferred  to  tracheotomy,  or  vice  versa,  has 
not  been  formulated,  but  probably  soon  will  be. 

The  following  is  a  summary  of  Dr.  E.  F,  Ingal's  description 
of  the  technique  of  the  operation  : 

"  The  child  should  be  wrapped  in  a  sheet  or  shawl,  which  will  pinion  the  arms, 
and  then  be  held  upright  in  the  nurse's  lap.   An  assistant  holds  the  child's  head.  The 


'Med.  Record,  February  21,  18S5. 

Chicago  Medical  Journal,  June,  November,  December,  1885  ;  and  March,  1886. 

Archives  Pediatrics,  November,  1885, 

New  York  Medical  Journal,  November  28,  1885,  and  April  3,  1886. 

Journal  American  Medical  Association,  February  6,  13  ;  July  10,  17, 1886. 

Medical  and  Surgical  Reporter,  March  20,   18S6. 

American  Journal  of  Obstetrics,  June,  18S6,  p.  657. 

Private  letter  from  Dr.  Waxham,  June  20,  1SS6. 


^3^  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

gag  is  then  introduced  between  the  jaws,  far  back  on  the  left  side  of  the  mouth,  and 
opened  as  wide  as  need  be,  but  not  with  great  force.  The  physician  sitting  in  front 
of  the  patient  passes  his  left  index  finger  over  the  base  of  the  tongue  and  down  be- 
hind the  epiglottis,  and  with  it  guides  the  end  of  the  tube  into  the  glottis.  The  end 
of  the  tube,  having  reached  the  pharyngeal  wall,  is  directed  downwards  and  forwards 
along  the  index  finger  into  the  larynx,  'under  and  not  over  the  finger' —  JVax/iam. 
Unless  he  is  careful  to  carry  the  handle  of  his  instrument  high  and  thus  bring  the 
tube  as  far  forward  towards  the  base  of  the  tongue  as  possible,  the  tube  will  be  passed 
into  the  oesophagus.  Too  great  haste  should  be  avoided.  If  the  tube  is  not  intro- 
duced in  ten  or-twenty  seconds,  it  should  be  removed  for  a  minute  or  two  to  allow 
the  child  to  breathe,  and  then  the  operation  maybe  repeated;  but  if  the  tube  seems 
to  be  in  the  proper  position,  whether  the  operator  is  certain  of  it  or  not,  the  slide 
should  be  crowded  forward  so  as  to  disengage  the  obturator,  which  is  then  with- 
drawn. Some  cough  will  occur  at  once,  and  if  the  tube  has  not  been  inserted  into 
the  larynx,  or  if  it  has  not  been  passed  down  so  that  the  rim  rests  on  the  vocal  cords, 
it  is  likely  to  be  expelled,  and  may  be  seen  or  felt  in  the  back  part  of  the  mouth.  If 
the  tube  has  been  properly  inserted  respiration  will  become  easier  in  a  few  minutes. 
The  operator  then  cuts  one  end  of  the  silk  thread  attached  to  the  upper  end  of  the 
tube,  passes  his  fingers  behind  the  epiglottis  and  holds  the  tube  while  the  thread  is 
withdrawn.  The  tube  may  remain  in  the  larynx  as  long  as  necessary  to  secure  per- 
fect respiration,  as  it  causes  little  if  any  irritation.  No  anaesthetic  will  be  needed 
for  the  introduction  of  the  tube,  but  one  will  occasionally  be  required  for  its  removal. 

Looking  at  the  intubation  of  the  glottis  from  our  standpoint,  it  seems  well  adapted 
for  the  following  cases : 

I.  For  diphtheritic  and  croupous  stenosis  of  the  larynx  occurring  in  children  under 
3^/2  years  of  asje.  2.  For  cases  of  these  same  affections  in  older  children  in  which 
from  any  cause  the  physician  wishes  to  defer  the  operation  of  tracheotomy.  3.  For 
those  cases  in  which  consent  to  tracheotomy  cannot  be  obtained.  4.  For  those  cases 
in  which  proper  nursing  could  not  be  secured.  5.  For  severe  cases  of  spasmodic 
croup  in  children  less  than  10  years  of  age.  6.  For  simple  stenosis  of  the  larynx, 
not  diphtheritic,  in  children.  7.  With  proper  sized  tubes  it  may  be  of  value  in  the 
treatment  of  various  forms  of  laryngeal  stenosis  in  adults." 

The  following  are  illustrations  of  the  instruments  used  by 
Dr.  O'Dwyer,  the  plates  of  v/hich  were,  by  his  permission,  fur- 
nished by  George  Tiermann  &  Co. : 


Fig.  a — Forceps  for  extractinc:  or  removing  Tube. 


SEQUELiE  OF  KTACHEOTOMY. 


637 


G.TIEMANn'&CI)! 


III    fer'tS;. 


■7  -^ 


if      it 


Fig.  C — Scale,  actual  size  — -  The  numbers  give  the  length  of  tubes  required  for 
children  of  corresponding  ages. 


Fig.  D — O'Dwyer's  Tube  and  Introducer. 


638  DIPllTHIERIA,    CROUP    AND    TRACHEOTOMY. 


Fig.   B — Mouth    Gag  as  used  by  Dr.  O'Dwyer.        Less  than  half  size. 

A.  Extractor,  about  two-fifths  normal  size. 

B.  Gag,  two-fifths  normal  size. 

C.  Scale  of  the  actual  sizes  of  tubes. 

D.  Tube  and  introducer. 

The  calibre  is  oval  and  is  Vs  by  7*  inches  in  the  largest 
one,  and  half  that  size  in  the  smallest.  Each  tube  has  at  its 
upper  extremity  an  eye  for  the  silk  thread  used  when  it  is 
being  introduced.  There  are  jointed  obturators  which  fit  each 
of  these  tubes  and  hold  them  while  being  introduced.  They 
are  jointed  in  order  that  they  may  be  more  readily  with- 
drawn when  the  tube  is  in  the  larynx. 

"Statistics  of  tracheotomy  and  of  intubation  of  the  larynx 
in  the  treatment  of  diphtheritic  croup  in  Chicago,  111."  (In 
abstract.) 


Tracheotomy. 

In  tracheotomy  there  were  fifty-two  operatoi-s,  or  reporters  who  report  from  one  lo 
thirty  three  operations  each — twelve  operators  reporting  one  each  ;  the  others  re- 
porting numbers  varying  to  the  highest  number.  Total  operations  306,  recoveries 
58,  percentage  of  recoveries  18.95.  In  138  cases  in  which  the  age  was  known,  the 
average  was  5  years  and  i  month. 

Intubation. 

Of  intubation  there  were  83  cases,  3  were  reported  by  Dr.  C.  P.  Caldwell,  5  by 
Dr.  E.  F.  Ingals,  7  by  Dr.  A.  B.  Strong,  10  by  Dr.J.R.  Richardson,  and  58  by  Dr.  F. 
E.  Waxham. 

The  results  were  as  follows  : 


SEQUELiE  OF  TRACHEOTOMY. 


639 


Cases. 


7 

2 
2 
2 

3 
I 

12 
I 
I 

14 

II 

I 

3 


10 

7 
Total,  83. 


Ages. 
9  months 
II      " 

13  "       - 

14  '• 

15  «       - 

16  « 

17  "       - 

18  « 


Recoveries. 
o 
o 
o 


2  years 

- 

- 

2  years, 

I 

mon:Ii 

2     " 

2 

"     - 

2     " 
2     « 

3 
6 

« 

3  years 

3  years   4   months 

3     "        6      «    - 


4   years 

4    years    9   months 

4    years   6   months 


7  years 

7  years   6   months 

8  years 
II  years 


? 


Average  age,  3  yrs.  7  mos. 


23 


The  percentage  of  recoveries  from  intubation,  27.71,  represents  the  percentage  of 
entire  recoveries  from  the  disease,  and  not  simply  recoveries  from  the  operation. 

Of  the  58  cases  coming  under  my  care,  20  were  actually  moribund  when  the  ope- 
ration was  performed,  many  of  them  entirely  unconscious,  and  40  were  bad  cases  of 
diphtheria,  characterized  by  extreme  exudation  in  the  pharynx  as  well  as  in  the  lar- 
ynx. In  18  cases  the  exudation  in  the  phaiynx  was  slight.  In  every  case  the  ope- 
ration was  performed  to  avert  impending  suffocation,  and  false  membrane  was  ex- 
pelled either  in  the  form  of  muco-pus,  shreds  or  casts. 


640 


DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 


In  addition  to  the  23  perfect  recoveries  from  the  disease  the  operafo  1  was  per- 
fectly successful  in  18  others,  although  the  patients  -'ied.  Thus  4  died  perfectly  easy 
before  the  removal  of  the  tube,  from  the  severity  of  the  diphtheritic  disease;  3  died 
easily,  from  one  to  several  days  after  the  tube  was  removed,  from  exhaustion  inci- 
dent to  the  disease.     One  died  of  paralysis  of  the  heart,  i  from  uraimic   convulsions. 


Ix-.^^c/r^'T-i! 


Antero-Posterior  Section  cf  the  Head,  showing  the  combined 
direction  of  Spray  Producers  Kos.  2,  3,  4  and  5  in  the  local  treat- 
ment of  the  pharyngo-nasal  and  nasal  cavities.  No.  2  is  introduced 
into  the  anierior  nares  (Rujibold)  . 

Fig.  41. 

3  from  pneumonia,  resulting  from  hypostatic  congestion  of  the  lungs,  and  6  from 
pneumonia,  resulting  from  unfavorable  surroundings.  These  cases,  added  to  those 
where  perfect  recovery  resulted,  and  the  total,  41  or  49.39  per    cent.,    represents    the 


I 


SEQUELAE  OF  TRACHEOTOMY. 


641 


proportion  of  cases  in  which  the  operation  was  successful  and  entirely  satisfactory; 
the  remaining  cases  dying,  generally,  from  extension  of  the  membrane  into  the  bron- 
chial tube. — F.  E.  Waxh"am.] 

Diphtheritic  Coryza. 


Antero-Posterior  Stction  of  the  Head.— Showing  the  combined 
direction  of  Spray  Producers  1,  6  and  7.  No.  8  throws  the  stream 
on  the  base  of  the  tongue.  These  Instruments  treat  the  pharynx, 
larynx  and  base  of  the  tongue  (Uumbold)  . 

Fig.  42. 


Insufflations  of  tannin,   alum,  flowers  of  sulphur,  or  better 
stiil,  injections  of  lime-water,  of  solutions  of  lactic   acid,   car- 


^42  DIPHTHERIA,     CROUP    AND    TRACHEOTOMY. 

bolic  acid,  salicylic  acid  [and  biniodide  of  mercury,  ^/som]  also 
peroxide  of  hydrogen,  20  grm. — Nunn],etc.,are  the  means  to  be 
employed  in  diphtheritic  coryza.  The  injections  should  be  re- 
peated four  or  five  times  a  day.  They  should  be  abundant  and 
made  by  means  of  an  irrigator  or  siphon.  A  canula  of  waxed 
leather,  or  better  still,  a  special  canula  of  ivory,  of  the  shape  of 
the  nostril  should  be  employed.  With  a  little  practice  on  the 
part  of  the  patient  the  velum  palati  contracts  in  such  a  way 
that  the  liquid  introduced  by  one  nostril  runs  out  by  the  other 
without  running  into  the  fauces,  provided  always  that  the  ob- 
struction be  not  complete.  In  such  a  case  it  -would  be  neces- 
sary to  wash  the  two  nostrils  alternately.  [The  spray  appa- 
ratus with  double  bulb  is  in  these  cases  very  convenient  and 
efficient.] 

PsEUDo-  Membranous  Bronchitis. 

When  the  diagnosis  can  be  positively  settled,  it  is  useful  to 
treat  the  bronchial  and  tracheal  false  membranes.  Internal 
measures  which  operate  by  bronchial  elimination  demand  too 
long  a  time.  Emetics  may  render  service,  but  they  should  be 
given  with  caution  for  fear  of  diarrhoea  and  depression  of  vital- 
ity. However  feeble,  in  such  cases,  its  action  may  be,  it  is  still 
preferable  to  have  recourse  to  topical  medication.  The  vapor 
of  water  charged  with  emollients  acts  as  a  local  bath,  but  this 
action  is  insufficient  in  the  case  in  question. 

Such  substances  as  modify  the  false  membranes  are  more 
indicated.  Inhalations  of  atomized  lime-water  or  dilute  lactic 
acid  may  be  employed,  and  the  atomization  made  in  front  of 
the  wound,  if  the  patient  has  been  tracheotomized.  But  the 
most  efficacious  means  consists  in  instilling  through  the  canula 
modifying  fluids.  Instillatio7is  were  at  first  made  with  tepid 
water  for  the  purpose  of  softening  the  false  membranes  and 
aiding  in  their  detachment.  Trousseau,  who  recommended 
this  treatment,  employed  the  water  in  quite  large  quantity,  a 
teaspoonful  at  a  time.  Struck  by  the  inconveniences  of  t^is 
method  which,  in  place  of  relieving  patients,  frequently  au;'- 
mented  their  dyspnoea,  he  renounced  it. 


SEQUELS  OF  TRACHEOTOMY.  643 

Barthez  took  up  the  same   idea  again,   and,   desirous   of  re- 
moving its  dangers,  adopted  the  following  procedure: 

The  water  is  warmed  to  a  temperature  between  30°  and  40° 
C.  {86°  to  104°  F.)  and  a  few  drops  are  drawn  into  a   pipette 
and    allowed  to  drop  into  the  canula.     A  paroxysm  of  cough- 
ing succeeds    this   instillation,  during  which   the    child    often 
ejects    pseudo-membranous    debris.     This    is    repeated   about 
every  half  hour,  except  when   the    patient    is    asleep.     Aside 
from  the  softening  of  the  false  membrane   which  it  may  bring 
about,  the  action   of  the  water  is  indirect  rather  than    direct, 
and  it  has  little  effect  except  in  exciting  cough.     It  has    also 
been  sought  to  bring  to  bear  upon   the  bronchial   and  tracheal 
exudations,  agents  capable  of  destroying  them.     Cauterization 
of  the  trachea  and  injection  of  a  solution   of  nitrate  of  silver 
have   been   tried;   but  these  useless  and    dangerous  methods 
were  very  quickly  renounced. 

Barthez,  utilizing  the  solvent  properties  of  the  alkalies,  had 
the  idea  of  instilling  them  into  the  trachea  in  the  form  of  solu- 
tion. After  several  trials  he  settled  upon  chlorate  of  sodium, 
whose  action  is  more  rapid  than  that  of  chlorate  of  potassium. 
The  solution  employed  is  saturated.  The  instillations  are  ef- 
fected by  the  procedure  above  indicated. 

Cough  comes  on  as  after  the  instillation  of  tepid  water,  but 
with  greater  energy.  The  action  of  the  chlorate  of  sodium  is 
not  limited  to  that.  In  children  submitted  to  this  treatment 
for  several  days,  the  false  membranes  are  found  at  the  autopsy 
to  have  been  softened  from  the  incision  in  the  trachea  down  to 
the  bifurcation  of  that  passage. 

The  action  of  these  instillations  does  not  appear  to  extend 
farther:  for  the  bronchial  false  membranes,  in  fact,  preserve 
their  form  and  consistence. 

While  this  desideratum  may  be  regretted,  it  is  none  the  less 
true  that  chlorate  of  sodium  by  instillation  constitutes  a  treat- 
ment which  can  render  service  against  the  generalization  of  the 
false  membranes,  whether  by  the  cough  which  it  excites,  or  by 
its  immediate  action  upon  the  exudate.  The  perfect  harmless- 
ness  of  this  agent  has,  likewise,  its  value  in  such  cases. 


^44  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

Barthez  has  also  tried  ammonia  in  solution,  one  in  twenty, 
but  the  cough   was  so  violent  that  he  had  to   renounce  this  ir-  • ; 

ritant  substance.  |ll 

Lime-water  and   lactic   acid  may  also   be   used,  but  it  must  ^} 

not  be  concealed  that  the  action  of  these  substances  upon  the 
false  membranes  of  the  bronchi  is,  so  to  speak,  nil.  [Neurin 
and  papyotin  have  been  recently  recommended  on  account  of 
their  dissolvent  action.] 

§5  • BlEPH  ARO-CONJUNCTIVITIS. 

Cauterization  and  blood-letting  should  be  proscribed.  The 
latter,  aside  from  the  harmful  effect  which  it  has,  in  general, 
upon  diphtheria,  finds  no  special  indication  in  this  particular 
case,  for  the  conjunctiva  is  rather  anciemic  than  congested. 
Cold,  and  even  iced  compresses,  frequently  renewed,  and  cool 
irrigations  are  of  great  service  against  the  pain  which  is  often 
intolerable.  The  false  membrane  should  be  touched  with  lime- 
water,  or  dilute  lactic  or  citric  acid.  After  each  application 
the  eye  should  be  washed  with  cold  water.  The  washing 
should  be  very  abundant,  and  repeated  three  or  four  times  a 
day,  and  at  each   operation  the  contents  of  a  large    irrigator  ] 

should  be  used.     When  the  elimination  of  the  false  membrane  ' 

is  accomplished,  resolution  should  be  hastened  by  the  instilla- 
tion of  slightly  astringent  collyria  of  nitrate  of  silver,  of  sul- 
phate of  zinc  or  sulphate  of  copper.  Cauterization  with  nitrate 
of  silver  should  be  avoided  as  it  endangers  damage  to  the 
cornea,  already  considerably  affected  in  its  vitality,  and  inclined 
to  mortification.  The  period  of  cicatrization  should  be 
watched  to  prevent,  as  far  as  possible,  vicious  adhesions  as 
symblepharon  and  entropion.  It  is  of  great  advantage  to  pro- 
tect the  healthy  eye  by  thorough  occlusion. 

§6. — Diphtheritic  Otitis. 

Otitis  media,  supervening  by  the  propagation  of  the  diph- 
theritic process  from    the    pharynx  to    the  tympanic    cavity, 


SEQUELiE  OF  RTACHEOTOMY.  645 

along  the  Eustachian  tube,  almost  always  goes  on  unperceived 
in  the  midst  of  the  symptomatic  complexus  of  which  it  is  one 
of  the  elements.  Otorrhoea  is  almost  the  only  symptom  which 
calls  attention  to  this  part,  but  the  evil  has  already  been  done, 
the  tympanic  membrane  is  perforated,  and  the  entire  surface 
of  the  cavity  and  the  external  meatus  is  often  covered  with 
false  membrane.  The  indication  for  treatment,  therefore,  gen- 
erally remains  hidden,  but  that,  however,  is  a  point  of  mediocre 
importance.  We  cannot  flatter  ourselves,  in  fact,  that  the  pro- 
cess could  have  been  prevented  had  it  been  recognized  from 
the  beginning.  The  false  membranes  can  no  more  be  pre- 
vented gaining  the  cavity  of  the  tympanum  than  they  can  be 
stopped  in  their  descent  to  the  bronchi.  When  they  reach  the 
external  meatus,  frequent  and  abundant  injections  of  a  solution 
of  carbolic  acid,  one  to  five  hundred,  should  be  employed. 

Four  injections  a  day  should  be  given,  and  each  one  should 
comprise  the  contents  of  a  large  sized  irrigator.  The  patient 
should  hold  his  head  strongly  inclined  toward  the  side  of  the 
diseased  ear,  and  over  a  basin. 

After  the  separation  of  the  false  membrane,  the  situation  no 
longer  differs  from  that  presented  by  ordinary  otitis  media 
ending  in  suppuration  and  perforation  of  the  tympanum.  The 
treatment  is  the  same.  An  attempt  is  made  to  arrest  the  dis- 
charge. For  this  -purpose  injections  of  simple  or  carbolized 
water  made  in  the  same  manner  are  continued,  but  they  are 
followed  each  time,  after  having  the  diseased  ear  inclined  far 
enough  to  empty  it,  by  instilling  a  few  drops  of  a  solution  of 
sulphate  of  zinc,  1%,  of  sulphate  of  copper,  1-2%,  or  of  pure 
sulphate  of  aluminum,  i  to  10%.  The  patient  should  be  care- 
ful to  retain  the  liquid  for  a  few  moments  in  contact  with  the 
cavity  of  the  ear,  which  will  be  accomplished  by  holding  the 
head  inclined  toward  the  side  opposite  the  diseased  ear.  Af- 
ter each  operation  the  ear  should  be  dried  and  then  stopped 
with  a  cotton  tampon. 

After  a  certain  period  of  this  treatment,  the  discharge  di- 
minishes and  finally  disappears,  and  the  hearing  may  return  to 
nearly  normal.     But  as  the  tympanic  membrane  is  absent  the 


646  DIPHTHIERIA,    CROUP    AND    TRACHEOTOMY. 

floor  of  the  ear  is  sensitive  to  atmospheric  changes.  Cold  and 
moisture  cause  a  return  of  the  discharge  and  of  the  deafness. 
The  patient  should  avoid  these  relapses  as  much  as  possible 
by  protecting  the  cavity  of  the  tympanum  by  a  tampon  of  cot- 
ton placed  in  the  external  meatus. 

§7. — Diphtheritic    Stomatitis. 

Chlorate  of  potassium  internally,  and  applications  of  lemon 
juice,  lactic  acid,  saccharate  of  lime,  etc.,  bring  it  easily  to  an 
end. 

§8. — Cutaneous  Diphtheria. 

The  diseased  surfaces  should  be  dusted  with  bicarbonate  of 
sodium,  calomel,  tannin,  flowers  of  sulphur,  etc.,  or  better,  cov- 
ered with  pledgets  of  charpie  dipped  in  lime-water  or  dilute 
lactic  acid. 

DiphtJieria  of  the  genital  organs  is  combated  by  the  same 
means. 

THIRD  CLASS. 

Treatment    of     Certain      Symptoms,    Complications     and 

Sequelae. 

Some  of  the  symptoms  of  diphtheria  assume  occasionally 
sufficient  importance  to  demand  special  treatment. 

Hemorrhage. — The  means  of  combating  losses  of  blood  de- 
pendent upon  tracheotomy  have  been  indicated  above.  Inde- 
pendent of  any  operation  other  hemorrhages  may  proceed  from 
the  mouth,  or  nose,  which  have  for  their  causes  profound  in- 
fection, the  elimination  of  eschars,  denuding  of  vessels,  etc. 
The  ansemic  condition  of  the  patient  demands  that  we  arrest 
this  new  source  of  destruction  of  vitality  as  quickly  as  possible. 

The  hemorrhage  which  is  seen  oozing  from  the  mouth,  and 
whose  source  is  accessible,  should  be  met  by  styptics,  and  es- 
pecially by  applications  of  perchloride  of  iron  combined  with  the 


i 


SBQUELiE  OF  TRACHEOTOMY.  64/ 

internal  employment  of  that  salt.  Epistaxis  may  be  attacked 
by  injections  of  perchloride  of  iron,  and  even,  as  a  last  re- 
source, by  tamponing.  But  these  methods  are  not  without  in- 
convenience, and  often  remain  useless.  It  is  not  without  dan- 
ger to  practice  tamponing  the  nasal  fossae,  covered  perhaps 
with  false  menibrane,and  whose  mucous  membrane  bleeds  easily. 

Cold  applications  are  more  advantageous  and  are  entirely 
harmless. 

In  case  of  buccal  hemorrhage,  and  even  of  epistaxis,  the  pa- 
tient should  be  made  to  take  a  teaspoonful  of  pounded  ice 
every  five  or  ten  minutes.  Under  the  influence  of  this  very 
simple  means,  the  bloody  discharge  is  rapidly  arrested.  Epi- 
staxis may  be  directly  combated  by  repeated  injections  of  ice- 
water. 

Alcoholic  liquors  internally  in  the  form  of  strong  wines, 
such  as  Marsala,  sherry,  etc.,  are  useful  as  adjuvants. 

Syncope. — That  which  comes  on  where  there  is  no  operation 
is  amenable  to  the  same  means  as  that  which  complicates 
tracheotomy. 

Gastro-Intestinal  Dishirbances. — We  will,  as  far  as  possible, 
avoid  producing  them,  by  being  very  cautious  in  the  use  of 
remedies  which  disturb  that  organ,  to-wit,  emetics,  mer- 
curials, balsamics,  etc.  If  their  employment  has  been  be- 
gun they  should  be  immediately  suspended.  In  case  this  pre- 
caution does  not  suffice,  the  use  of  bismuth,  of  diascordium  (an 
aromatic  electuary  or  confection  of  laudanum),  enemata,  etc., 
should  be  prescribed. 

Adenitis. — During  the  first  stage,  recourse  should  be  had  to 
cataplasms  or  to  oily  embrocations,  after  which  the  neck 
should  be  surrounded  with  a  layer  of  cotton  wadding.  But 
when  suppuration  has  appeared,  exit  must  be  given  to  the  pus. 
The  necessity  for  this  is  so  much  the  more  pressing  as  we  of- 
ten find  ourselves  in  the  presence  of  two  abscesses,  one  in  the 
glands,  and  the  other  in  the  surrounding  cellular  tissue.  While 
the  glandular  abscess  progresses  quite  slowly  and  shows  but 
little  tendency  to  spread,  it  is  not  so  with  the  other.  It  extends 
itself  rapidly  and  sends    out  burrows   which  produce  extensive 


648  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

separations,  and  dissects  the  muscles  of  the  neck.  The  pus 
should,  therefore,  receive  a  prompt  exit.  Its  quantity  varies 
with  the  time  of  openin^r.  But  we  must  not  think  that  every- 
thing is  ended  because  the  incision  has  been  made  and  the  pus 
discharged.  Certain  peculiarities  and  difficulties  are  to  be 
counted  upon,  which  it  is  well  to  know. 

It  is  quickly  perceived  that  the  abscess  is  composed  of  two 
cavities,  one  superficial  and  subcutaneous,  and  the 
other  deep,  and  formed  at  the  expense  of  one  or  more  glands. 
These  two  pockets  are  united  by  a  narrow  channel  through 
which  the  pus  makes  it^  way  with  difficulty.  Moreover,  while 
the  superficial  collection  discharges  itself  easily,  pus  accumu- 
lates in  the  other,  and  does  not  run  out  except  on  pressure. 
Further,  a  grooved  probe  must  be  introduced  into  the  fistula, 
the  groove  facilitating  the  exit  of  pus.  This  is  the  form  of  ab- 
scess called,  boiiton  de  chemise.  If  this  condition  is  not  rem- 
edied the  collection  increases  and  separation  of  tissues  (bur- 
rowing) is  produced. 

The  enlargement  of  the  outlet  by  incision  has  only  a  tem- 
porary influence.  It  is  found  closed  the  next  day  even  when 
it  is  attempted  to  maintain  the  dilatation  with  a  tent.  More- 
over, the  tent  has  the  disadvantage  of  acting  as  a  plug  and 
preventing  the  exit  of  the  pus.  It  is  useful  when  the  cavity  is 
considerable,  to  make  one  or  more  counter  punctures  into 
which  drainage  tubes  are  passed.  But  this  procedure  is 
scarcely  applicable  except  to  the  superficial  cavity.  The  un- 
dertaking is  more  difficult  when  it  is  a  matter  of  going  deeply 
into  the  glandular  mass.  It  is  not  always  prudent  to  push  a 
trocar  far  in  the  neighborhood  of  organs  which  must  be  re- 
spected. 

I  have  found  it  well,  in  several  cases  of  this  kind,  to  dilate 
the  opening  with  a  bit  oilaviinaria  digitata.  A  piece  must  be 
chosen  which  has  been  formed  into  a  tube.  This  arrangement 
prevents  the  retention  of  the  pus  while  dilation  is  going  on. 
The  opening  contracts  quite  promptly  and  one  operation  rarely 
suffices ;  so  recourse  must  again  be  had  to  laminaria.  This 
quite  painful   procedure  should  not  be  repeated  except  at  the 


SEQUELiE  OF  RTACHEOTOMY.  649 

moment  when  it  becomes  absolutely  necessary.  To  avoid  this 
alternative  I  have  taken  the  position  of  managing  the  discharge 
ofthepus,  by  means  of  a  kind  of  permanent  canula.  This  is 
how  I  proceed :  I  take  a  gum  catheter  of  proper  size  and 
leave  it  of  such  a  length  as  will  reach  to  the  bottom  of  the 
pocket  and  extend  some  millimeters  ('/g  inch)  beyond  the  ori- 
fice in  the  skin.  I  cut  it  off  at  both  ends,  as  the  pus  passes 
more  easily  through  a  circular  orifice  situated  in  the  axis  of  the 
instrument,  than  through  lateral  eyes.  Finally,  I  fasten  a  stout 
thread  to  the  end  which  is  to  project  externally,  which  thread 
is  there  fastened  to  two  pieces  of  tape  just  as  in  a  tracheotomy 
canula.  The  catheter,  previously  oiled,  is  introduced  into  the 
fistula,  the  tapes  are  then  tied  around  the  neck  just  like  those 
of  the  canula  for  tracheotomy.  The  whole  is  covered  with  a 
poultice.  This  dressing  is  not  painful ;  and  it  retains  its  place 
perfectly  when  care  is  taken  not  to  leave  the  external  end  too 
long,  otherwise  it  works  out  of  the  wound.  The  pus  dis- 
charges with  the  greatest  facility,  the  pocket  empties  itself, 
shrinks,  and  a  cure  is  rapidly  obtained. 

Pulmonary  Inflammations. — Vesicants  should  be  shunned, 
at  least  during  the  first  stage  of  the  disease.  As  long  as  the 
economy  remains  under  the  diphtheritic  influence  the  denud- 
ed surface  is  liable  to  become  covered  with  false  membrane. 
This  is  an  aggravation  which  should  be  avoided. 

Internally,  sulphuret  of  antimony  may  be  given  in  small 
doses,  .05  ('Yi  gr-)  at  most,  discontinuing  it,  however,  if  it 
cause  nausea  or  anorexia  or  produce  a  purgative  effect. 

The  medication  which  has  the  most  rational  basis  is  the 
treatment  by  alcohol.  The  tendency  toward  depression  which 
lies  at  the  base  of  diphtheria  demands  this  method  of  thera- 
peutics. From  40.  to  6o.  (lO  to  153)  of  brandy  should  be  given 
according  to  age.  The  proper  dose  is  such  an  amount  that 
the  alcohol  shall  stimulate,  not  depress. 

Pulmonary  complications  such  as  gangrene,  apoplexy, 
oedema,  etc.,  are  not  usually  recognized  except  at  the  autopsy. 
I  will  not  speak  of  their  treatment  which,  however,  presents 
nothing  peculiar  in  this  instance. 


650  DIPHTHIERIA,    CROUP    AND    TRACHEOTOMY. 

Diphtheritic  paralysis. — When  the  paralysis  is  slight  and 
confined  to  the  velum  palati,  the  only  proper  treatment  is 
electrization.  The  affected  muscles  should  be  excited  by 
means  of  the  induced  current. 

Care  should  be  taken,  at  the  same  time,  to  allow  the  patient 
but  little  drink  or  liquid  food.  These  substances  are  thrown 
out  through  the  nose  or  into  the  air-passages,  at  every  move- 
ment of  deglutition,  whence  there  arises  on  the  part  of  the 
child,  an  intense  disgust  and  dread  which  makes  him  refuse 
all  nourishment.  Solid  food  should  be  discarded  also,  for  the 
patient,  in  fact,  masticates  poorly  and  sometimes  allows  bits  of 
meat  or  other  substances  to  fall  into  the  trachea,  causing  death 
by  suffocation.  Bits  of  unmasticated  meat  have  been  found  in 
the  bronchi  of  paralytics  who  had  died  suddenly.  The  meals 
should  be  composed  of  thick  soups  and  panadas,  or  of  very 
thick  porridges  of  pea  soup  containing  also  a  large  proportion 
of  meat  finely  chopped  and  pressed  through  a  sieve. 

For  the  purpose  of  facilitating  deglutition  in  case  of  paraly- 
sis, Perrin  recommends  placing  the  child  flat  on  its  belly,  over 
the  knees  of  the  person  who  is  feeding  it,  in  such  a  way  that 
the  face  of  the  patient  shall  be  inclined  and  turned  toward  the 
floor.  In  this  position  a  flat  plate  full  of  any  liquid,  milk, 
broth,  porridge,  etc.,  is  brought  close  to  his  lips.  Then  the 
plate  is  gradually  removed  in  such  a  way  as  to  oblige  the  pa- 
tient to  stretch  his  neck  and  elongate  his  lips  so  as  to  practice 
a 'real  suction  of  the  liquid.  Applied  to  a  patient  of  four  years 
that  expedient  was  crowned  with  success.  It  was  the  same  in 
another  case  with  a  little  patient  aged  twenty-three  months, 
who  had  been  operated  upon,  and  whom  the  author,  in  con- 
cert with  Archambault,  was  attending.  The  method  of  pro- 
cedure was  still  more  simple,  for  we  were  content  with  placing 
the  body  of  the  child  in  supination,  the  head  situated  lower 
than  the  shoulders,  and  making  him  drink  slowly  and  carefully 
from  a  spoon. 

Tonics,  such  as  Peruvian  bark,  the  bitter  and  the  ferruginous 


SEQUEL.E  OF  TRACHEOTOMY.  65  I 

tonics  of  every  form,  together  with  sulphur  baths,  should  be 
added  to  the  preceding  measures.  When  the  paralysis  has  be- 
gun to  decline,  preparations  of  nux  vomica  are  of  service  in 
exciting  muscular  contractility.  We  must  avoid  giving 
them  at  the  beginning,  for  they  then  do  more  harm  than  good. 

However  advantageous  these  therapeutic  agents  may  be, 
one  only  is  indispensable,  and  this  is  electricity.  The  induced 
current  should  be  applied  to  the  velum  palati,  by  means  of 
special  electrodes.  Still  further,  one  of  the  electrodes  can  be 
placed  upon  the  velum  palati,  and  the  other  upon  the  m.astoid 
process.  Onimus  advises  the  application  of  the  two  electrodes 
of  a  continuous  current  either  upon  the  anterior  portion  of  the 
neck,  or  one  upon  that  part  and  the  other  upon  the  nucha. 
Every  time  that  an  interruption  of  the  current,  and  especially  a 
change  of  the  polarity  is  made,  there  is  produced  a  complete 
movement  of  deglutition. 

When  the  paralysis  affects  the  muscles  of  the  eye,  and  even 
those  of  accommodation,  the  continuous  current  gives  also  ex- 
cellent results.  Care  should  be  taken  to  place  the  negative 
pole  upon  the  nucha  and  the  positive  pole  at  the  orbit.  Cam- 
uset  has  reported  a  case  of  success  obtained  by  this  method. 
When  the  paralysis  becomes  general,  other  means  should  be 
associated  with  the  foregoing.  Hydrotherapy,  which,  accord- 
ing to  H.  Weber,  succeeds  still  better  than  electricity,  gives 
good  results  and  may  be  employed.  Sea  bathing  is  also  of 
use  in  perfecting  the  cure.  In  grave  cases  the  pointed  cautery 
applied  along  the  vertebral  column,  has  been  used  with  success. 
and  likewise  application  of  ice  in  the  same  region  (David  Eas- 
ton).  Billiard  notes  good  effects  from  sinapisms  and  vesicants 
upon  the  chest,  to  combat  the  paralysis  of  the  respiratory 
muscles. 

To  prevent  the  extension  of  the  paralysis  to  the  heart, 
Duchenne,  of  Boulogne,  advises  faradization  of  the  precordial 
region. 


PROPHYLAXIS. 


Are  there  any  means  of  preventing  diphtheria? 

As  the  disease  is  epidemic  and  contagious,  we  should  at- 
tempt to  arrest  the  development  of  the  epidemic.  The  only- 
rational  and  effectual  means  is  the  isolation  of  the  patients  and 
their  sequestration  in  a  remote  place.  Though  practicable  in 
hospitals  and  in  small  localities  where  the  cases  which  arise 
are  immediately  recognized,  this  system  is  almost  illusory  in 
the  great  centers  where  numerous  cases  may  remain  unknown. 
Theory  demands  isolation  in  these  cases,  as  in  the  preceding, 
but,  unfortunately,  these  measures  of  precaution  have  not  en- 
tered into  practice  [not  fully]  and  diphtheria  has  become  en- 
demic in  the  large  cities,  It  would  be  advisable  to  have  isola- 
tion rigorously  enforced  in  hospitals.  There  are  too  many 
patients  who  enter  for  various  diseases,  and  who  contract  in 
the  wards  a  diphtheria  which  is  often  fatal.  The  physicians  of 
the  hospitals  of  Paris,  and  of  most  of  the  large  cities  of  France, 
are  perseveringly  demanding  the  application  of  these  meas- 
ures, to  all  contagious  diseases.  Their  efforts  have  not  yet 
succeeded  in  overcoming  deeply  rooted  customs.  Yet,  in 
presence  of  the  growing  ravages  of  diphtheria,  it  is  fitting  that 
these  sanitary  safeguards  should  be  adopted  as  soon  as  possible. 

What  cannot  be  obtained  in  large,  crowded  populations,  nor 
as  yet  in  the  hospitals,  should  be  enforced  in  families.  It  is  a 
fact  that  one  case  of  diphtheria  is  almost  always  followed,  in 
such  circumstances,  by  one  or  more  others  when  the  members 
of  the  family,  especially  the  children,  remain  in  communica- 
tion with  the  patient,  while  those  who  are  removed  in  time,  are 
oftener  spared.     All  authors,  ancient  as  well  as  modern,  agree 

(632) 


SEQUELAE  OF  TRACHEOTOMY.  '  653 

upon  this  point.  Those  whom  it  is  desired  to  protect  should 
be  sent  off,  not  to  a  neighboring  room,  nor  in  the  same  house, 
but  to  a  distance,  and  as  far  as  possible.  When  it  is  desired 
to  have  them  return  to  their  dwelling,  care  should  be  taken  to 
submit  the  apartment  to  thorough  disinfection.  Furniture, 
carpets  and  hangings,  which  serve  as  receptacles  for  the  mor- 
bific germs,  should  be  beaten  and  cleaned,  and  disinfectant  fu- 
migations should  be  rigorously  made.  Floors  and  painted 
(wood)  work  should  be  washed.  Return  should  not  be  al- 
lowed until  after  the  strict  application  of  these  measures.  Be- 
yond that,  it  is  necessary  to  wait  long  enough  to  be  sure  that 
the  persons  who  have  remained  in  contact  with  the  patient  do 
not  themselves  take  the  disease.  But  as  the  incubation  of 
diphtheria  may  last  for  eight  days,  those  who  have  been  sent 
away  should  not  be  allowed  to  re-enter  their  dwelling  under 
eight  days  at  least.  If  possible  the  period  of  delay  should  be 
prolonged.  But  certain  persons,  the  physician  and  the  pa- 
rents, remain  in  contact  with  the  patient;  have  they  any  means 
of  preventing  the  disease? 

The  first  of  the  precautions  is  to  allow  to  remain  only  as 
many  persons  as  it  is  strictly  necessary  in  the  patient's  room. 
In  that  way  each  one  will  not  remain  so  long  in  contact  with 
\.\\<t  fojuesniorbi.  The  patient  himself  will  profit  by  this  meas- 
ure by  escaping  the  inconveniences  of  crowding.  Parents 
must  avoid  holding  the  child  constantly  in  their  arms,  embrac- 
ing him  every  moment,  and  directly  inhaling  his  breath.  This 
is  one  of  the  points  upon  which  the  physician  will  meet  the 
strongest  opposition.  Maternal  tenderness  refuses  to  listen  to 
the  advice  of  prudence.  She  is  determined  to  give  herself  en- 
tirely to  the  suffering  child,  and,  always  ready  for  sacrifice,  she 
is  reckless  of  the  danger. 

Wounds,  chaps  or  denuded  surfaces  should  be  carefully  pro- 
tected. Free  ablutions  with  water,  or  better  still,  with  a  solu- 
tion of  carbolic  or  salicylic  acid  are  indespensable  to  those 
:ontaminated  by  diphtheritic  products,  especially  when  these 
TiAterials    have  been  received  upon   mucous   surfaces,   in  the 


6S4  DIPHTHERIA,  CROUP  AND    TRACHEOTOMY, 

mouth,  upon  the  hps,  in  the  orifice  of  the  nostrils,  or  upon  tlie 
conjunctiva. 

These  recommendations  apply  particularly  to  the  physician 
who  operates  and  attends  to  the  dressing  of  the  patient;  for 
we  know  how  frequently  they  are  soiled  with  blood  and  with 
fragments  ^  false  membrane.  Although  neglect  of  this  pre- 
cept is  not  always  followed  by  accident,  it  is  not  right  to  neg- 
lect it.  Cases  of  diphtheria  developed  by  contact  with  the 
false  membranes  are  too  well  established  not  to  be  taken  into 
account.  To  act  otherwise  would  be  exposing  oneself  gratiu- 
tously.     [See  pages  539-540.] 

I  shall  say  as  much  for  that  heroic,  but  useless  as  well  as 
dangerous  act,  of  applying  the  mouth  to  the  wound  for  the 
purpose  of  sucking  out  the  blood  which  has  flowed  into  the 
trachea. 

Preventive  properties  have  been  attributed  to  several  sub- 
stances. Bicarbonate  of  sodium  has  been  advised  by  Moure- 
mans  and  by  Baron ;  sulphur  was  recommended  by  Duche, 
and  bromine  by  Ozanam.  The  worthlessness  of  these  means 
is  everywhere  recognized. 

Racle,  of  Constantine,  (Algiers),  considers  acetic  acid  as  a 
very  sure  preventive.  It  would  be  very  fortunate  if  acetic  acid 
should  be  found  possessed  of  these  valuable  properties.  I 
have  seen  this  agent  employed  only  once.  It  was  in  a  family 
where  I  had  performed  tracheotomy  upon  a  child  with  croup. 
Gargles  of  vinegar  did  not  prevent  the  father  from  contract- 
ing the  disease,  which  killed  him  after  extending  rapidly  from 
the  tonsils  to  the  larynx  and  the  bronchi. 

The  conjectured  inoculability  of  diphtheria  has  been  the  oc- 
casion of  imitating  in  this  disease,  that  which  has  been  done 
for  small  pox.  Doctor  Mazotto  performed  inoculation  fifteen 
times  as  a  curative  measure,  at  the  beginning  of  the  disease, 
and  twenty  times  as  a  preventive  measure  upon  subjects  liv- 
ing in  a  diphtheritic  focus.  The  patients  of  the  first  series 
were  affected  with  benign  forms  only ;  while  those  of  the  sec- 
ond class,  it  is  said,  were  spared,  all  except  two ;  but  these 
latter  had  only  very  slight  manifestations,  (See  p.  332  et  seq.) 


SEQUELS  OF  TRACHEOTOMY.  655 

We  would  greatly  deceive  ourselves  in  founding  any  hopes 
whatever  upon  these  instances.  It  is  known  how  questionable 
the  experimental  inoculation  of  diphtheria  is.  There  is  noth- 
ing to  prove  that  the  inoculation  was  effective  in  a  single  one 
of  these  patients,  for  no  valid  scientific  proof  has  been  pro- 
duced to  sustain  it ;  and  further,  in  the  two  cases  where  diph- 
theria followed  the  supposed  inoculation,  the  disease  declared 
itself  twenty  and  twenty-two  days  after  the  puncture.  The  ex- 
aggerated duration  of  the  incubation  gives  reason  to  believe 
that  the  disease  emanated  quite  in  the  usual  manner  from  the 
morbid  focus  in  which  the  patients  were  living. 

We  do  not  know,  therefore,  any  drug  which  will  certainly 
prevent  diphtheria,  and.  a  preservative  from  that  disease  is, 
like  its  specific,  wanting  up  to  the  present  time.  [E.  M.  Hunt 
recommends  internal  administration  of  chlorate  of  potash, 
combined  with  local  applications  of  chloride  of  iron.] 

[The  Council  of  Hygeine  of  France  has  voted  the  following 
instructions  (Jour,  de  Med.  et  de  Chir.)  Jour.  Am.  Med.  Assoc, 
vol.  iii.  No.  19,  Nov.  8,  1884).  They  contain  so  much  in  so 
brief  a  space  that  I  shall  insert  them  here.  The  Illinois  State 
Board  of  Health  issued  a  circular  on  diphtheria  in  1883,  con- 
taining the  same,  and  other  points  more  elaborately  set 
forth. 

The  Council  of  Hygiene  says  : 

Preservative  Measures. — Diphtheria  is  a  contagious  affection. 
All  association  of  children  with  persons  infected  by  it  should  be 
interdicted.  No  medicine  is  known  to-day  that  is  protective 
against  diphtheria.  It  is  important,  particularly  during  the 
prevalence  of  epidemics,  to  nourish  children  as  carefully  as 
possible,  and  to  see  that  they  are  not  subjected  to  the  pro- 
longed influence  of  moisture  and  cokl.  It  is  very  important 
to  tend  to  all  throat  affections  at  their  onset. 

Measures  to  be  taken  zvhen  a  case  of  diphtheria  appears  in  a 
family. — It  is  indispensable  to  remove  the  case  at  once  from 
all  communication  with  other  persons,  especially  children,  who 
are  not  concerned  in  the  treatment  of  the  disease.  Those  who 
wait  upon  the  case  should  not  embrace  the  patient,  inhale  the 


656  DIPHTHERIA,    CROUP    AND    TRACHEOTOMY. 

breath,  or  stand  in  front  of  the  mouth  of  the  patient  during  at- 
tacks of  coughing.  If  they  have  any  cracks  or  sores  on  the 
hands  or  face,  they  should  cover  them  carefully  with  collo- 
dion. 

They  should  be  well  nourished  and  go  out  into  the  fresh  air 
several  times  every  day,  taking  the  precaution  of  first  washing 
the  hands  and  face  with  water  containing  to  the  quart  about 
three  teaspoonfuls  of  crystalized  boracic  acid,  or  15  grains  of 
thymic  acid.  They  should  be  careful  not  to  remain  night  and 
day  in  the  room  of  the  patient. 

Measures  of  disinfection  in  the  course  of  the  disease  of  in  the 
case  of  death. —  i.  The  matters  discharged  by  cougiiing  or 
vomiting  should  be  destroyed  by  the  aid  of  a  solution  contain- 
ing 50.  (5jss)  of  chloride  of  zinc  or  sulphate  of  copper  to  the 
quart  of  water.  The  soiled  linen,  clothes,  etc.,  should  be  im- 
mediately washed  in  one  of  these  solutions,  and  then  plunged 
into  water  which  is  kept  boiling  for  an  hour  at  least.  The 
spoons,  glasses,  etc.,  after  being  used  by  the  patient,  should  be 
plunged  into  boiling  water. 

2.  Whatever  be  the  result  (or  cause)  of  the  disease,  disin- 
fection is  indispensable.  Fumigations  with  sulphur  are  to  be 
conducted  as  follows  :  After  closing  all  openings,  an  earthen 
pan  containing  hot  coals  is  to  be  placed  upon  sand,  and  on  it 
powdered  sulphur  to  be  placed  proportional  in  amount  to  the 
size  of  the  room  (20  grammes,  or  5v,  to  the  cubic  metre).  The 
chamber  must  remain  closed  for  twenty-four  hours,  and  then 
be  freely  aired.  The  clothes,  linen  and  other  cloths  used  by 
the  patient  are  to  be  disinfected  by  the  solutions  mentioned 
before  being  sent  to  the  wash.  The  mattress  should  be  opened 
and  left  in  the  chamber  during  the   fumigation.] 

The  only  measure  which  deserves  confidence  is  the  prompt 
removal  of  healthy  subjects  who  are  in  morbific  foci  (a  con- 
taminated locality).  I  therefore  repeat  with  Alaymo,  "Caveant 
angue  pejus  parentes  suos  filios  secum  gerere,  ubi  puerulus 
hoc  modo  infirmatur ;  et,  si  in  domo  ejus  continget,  statim 
alios  pueros  valetudine  fruentes  separent;"  and  with  Carne- 
vale,  *'  Cede  cito,  longinquum  abi,  seriusque  reverte." 


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xsSS 


BIOMQ  DEC  02 

BIOMFD  '  1" 

BEC  1 3 1985 

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BiOMED   DEC  16  •8/1 


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Form  L9-30)«-7r**(C824s4)444 


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